DENTAL RECORDS RELEASE FORM - ProSites, Inc. 2026

1. Click ‘Get Form’ to open the DENTAL RECORDS RELEASE FORM in the editor.
2. Begin by entering the Patient’s Name in the designated field. This is essential for identifying the records being requested.
3. Next, fill in the Date of Birth and Phone Number to ensure accurate identification and contact information.
4. Provide details of your Previous Dentist/Practice, including their Phone number and Address, City, Zip Code, and State. This information helps facilitate the transfer of records.
5. Indicate whether this request applies to yourself or other family members by checking the appropriate box. If applicable, list the names of family members for whom you are requesting records.
6. Authorize the release of your dental information by signing in the Patient Signature field (or Parent if a minor) and entering the Date Signed.
7. If you prefer digital records, include an email address (info@smileduluth.com) for sending your current x-rays directly.

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