13802 W Camino del Sol Suite #101
Sun City West, AZ 85375

(623) 583-0151

Records Request from the Village Dental Center

authorize The Village Dental Center to release my records to the following recipient via email.

I understand that typing my name constitutes a legal signature when submitting this form.

Latest Full set of x-ray or Pano & Bitewings and Periodontal Charting will be forwarded.