Record Release Request

If you require your dental records to be sent to an individual or other health office, please fill out the request form below. The information that may be released would include, but not limited to, dental records, appointment information, and treatment information. Alexandria Children's Dentistry cannot control how the recipient uses or shares this information, and laws protecting its confidentiality at our office may or may not protect this information once it has been disclosed to the recipient. Information will not be released without a valid signature from the patient (or patient's guardian). This authorization will take effect from the signature date and remain in place until you cancel the authorization in writing.

Record release requests will take 2 weeks to process.

If you do need records sent sooner, please call our office. Our front desk team will be happy to accommodate your needs. 

Bold fields are required.

Patient Name First and Last Guardian Name First and Last Guardian Email Address
Phone Number Reason For Leaving

 

Release my protected health information to the following physician/person/facility/entity:

Name and Email of Provider First and Last Relationship (Doctor, School Nurse, Teacher, Family Member) New Appointment Scheduled For MM/DD/YYYY

Submit Request