Record ReleaseDate Received* MM slash DD slash YYYY Name and Date of Birth of Child/Children*NameDate of Birth X-rays Only or Full written Records/HistoryReason for RecordsIf transferring to a new office, please list the appointment date MM slash DD slash YYYY Please choose an option to have records sent:Email records and/or x-rays to* Dental Office Personal Personal Email* Dental Office Email* If sending to personal email* Encrypted Unencrypted Or Mail them toParent/Guardian Email* Parent/Guardian (or if patient 18 years or older they must sign)* NameThis field is for validation purposes and should be left unchanged.
