Records Release

Record Release

Patient First Name

Patient Last Name

Birth Date

DENTAL RECORDS / X-RAY RELEASE FORM

Previous Dentist Name

Address

Phone Number

I give authorization to release my dental x-rays and dental records to the office of Imperial Dental Associates for my continued treatment.

Imperial Dental Associates
15 Imperial Avenue
Westport, CT 06880
(203) 227-2520
reception@genidmd.com

Signature of:

Patient Legal Guardian Parent Agent Under Durable Power of Attorney

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