Dental Record & Radiograph Release Form Often times it is necessary to obtain your complete dental history in order to devise a treatment plan that will properly address all your immediate and long-term dental needs. This consent gives our office permission to obtain those records on your (or your dependents) behalf.Patient Name Date of Birth Month Day Year Previous Dental Office Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code I authorize Evergreen Dental to request and receive any and all previous dental or medical charting as they pertain to the above-named patient’s dental and treatment. Please remit any current radiographs or pertinent dental information to: Evergreen Dental J. Scott Travelstead D.M.D. 1823 NW Kings Blvd. Corvallis, OR 97330 (541)754-6400 FAX: (541)754-2081 [email protected]Print Name of Patient or Legal Guardian* By typing your full name here, you are electronically signing this document.Today's Date Month Day Year Signature of Patient or Legal GuardianDate of Birth Month Day Year All patients over the age of 18 MUST sign their own forms. Patients under the age of 18 CAN NOT sign for themselves. Only a parent or legal guardian may sign for a patient under the age of 18.
