The Village Dental Center

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(623) 583-0151

Records Request from the Village Dental Center

I (Patient Name): Required

Date of Birth: Required

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.

Office/Doctor's Name: Required

Phone: Required

Fax #:

Email:

Address:

Address 2:

Patient / Guardian Signature: Required

Date: Required

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

Please indicate feedback for your request:

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