Dental Record & Radiograph Release Form Oftentimes 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 NameDate of Birth DD MM YYYY Previous Dental OfficeAddress 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]Name of Patient or Legal GuardianBy typing your full name here, you are electronically signing this document.Today's Date DD MM YYYY Date of BirthAll 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.
