Record Release - Woodland Dental

Dental Records Release
Name of Patient

Patient's First NamePatient's Last Name
Maiden Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Previous Dentist Office
Previous Dentist - Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Please forward the following information:
Comprehensive Exam & Date:

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Fluoride

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Prophy

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Bitewings

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Pano

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
I hereby give you permission to release any and all my dental records to Ryan L. Anderson, DDS at Woodland Dental.
Patient Signature (parent if a minor)
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please include the following dependant records:
Please mail or email records to:
Woodland Dental
PO Box 625 Wadena, MN 56482
woodlanddental@arvig.net
Should be Empty:

Dental Records Release