Record Release Form

Record Release
Date *

Month Day Year
Date
I, (full name)* , do hereby authorize the release of all dental records including x-rays from the office of (name)* to be sent to (Office name)*, at (Street # & Name)* in (Town & State)*.
I also release the above named offices from all legal responsibility that may arise
from this authorization.

If sending information to Mystic Dental Group, please send to:
email: mdg-mdg@snet.net
fax: 860-572-1409
Patient Name *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Signature (patient or person authored to sign for patient) *

Clear
Should be Empty:

Record Release