Dental Hygiene Clinic X-ray and Records Release Request

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Dental Hygiene Clinic

X-ray and Records Release Request

If you have visited the Dental Hygiene Clinic and would like to send your most recent X-ray or other records via electronic transmission in a non-encrypted format to a dentist or other service provider, complete this form.

Are you the patient or a parent/guardian?

Patient

Parent/Guardian

Requestor Email:

Patient First Name:

Patient Last Name:

Patient Date of Birth:

Recipient Name (DDS or Other):

Recipient Email:

What would you like us to send?

Most Recent X-rays

Other

By submitting this form, you are consenting to the electronic transmission of your X-rays or other requested records in a non-encrypted format.

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