Release of Records

Authorization to Release Dental Records

 

 

Date ___/____/_____

 

Patient’s Name_________________________________________________

 

I authorize the release of all current dental records and x-rays from:

Dr’s Name: _________________________________________________

Address: ___________________________________________________

City: _______________________________________________________

State: _____________    Zip Code: _______________________________

 

 

To:  Dr Richard J Stuart

        3021 E 98th St., Suite 240

        Indianapolis, IN  46280

 

Digital records: Please e-mail to amy@richardstuartdds.com

 

Authorized Signature: ________________________________________  Date: __/__/__

3021 E. 98th St.   |   Indianapolis, IN 46280   |   

ACCESSIBILITY