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.

  • 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]

  • By typing your full name here, you are electronically signing this document.
  • 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.