Patient Release of Dental Records

Your Name (required)

Your Email (required)

I authorize my records to be released and all images/ x-rays or pertinent records be emailed/sent securely to Robert Derr and Amy Chi Family Dentistry. Please email them to info@DentistEP.com
Previous Dental Office name

Previous office email address

Previous-dental-office-phone

Date of x-rays:
Type of images
Date of panoramic FMX (full mouth)
Date of Bitewing Images:
Signature:

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