X-Ray & Records Release

Use this form to request that our office send your pertinent information (x-rays, periodontal charting, etc.) to another provider, or have other providers send their information to us.

X-Ray & Records Release 

You can print it, fill it out, and mail it to the doctor you’re requesting information from, or save a copy to your computer (File > Save As…) and use Adobe or some other editing program to fill it out before emailing it to us.