Records Release

Dental Records Release Authorization

Patient Name

Date of Birth

I authorize the release of my dental records, including X-rays, treatment notes, periodontal records, photographs, and other records related to my dental care.

Release Records From

Office/Provider Name

Phone/Fax

Release Records To: Gregory J. Schmitt DMD

Phone/Fax/Email: 203-874-3003, 203-874-5193, office@gregoryjschmittdmd.com

*DEXIS Format preferred if available.

I authorize the above records to be released for the purpose of continuing or coordinating my dental care. I understand that I may revoke this authorization in writing, except for records already released.

Patient Authorization

Patient/Authorized Representative

Electronic Signature

Date

Relationship to Patient (if applicable)

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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