DENTAL RECORDS RELEASE

I
hereby request and authorize
to disclose and provide copies of any and all clinical records including but not limited to x-rays, perio charting and chart notes to the following:
BlueSky Dental 2500 West A Street Suite 204 Moscow ID 83843 info@blueskydentistry.com 208-882-9111 (Phone) 208-882-3279 (Fax)

(Please email x-rays and history, including all placement dates for crown, bridges, etc if possible)
I expressly release from liability the above named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.
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