Release Form

Authorize your prior dentist to share your records by completing this secure release form

This field is for validation purposes and should be left unchanged.
Patient's Name(Required)
MM slash DD slash YYYY
Fill out the email address of the practice releasing/requesting information.
(Required)
South Waterfront Dental
Todd L. Beck, DMD
3580 S River Pkwy,
Portland, OR 97239
info@southwaterfrontdental.com
503-841-5658
Patient's signature(Required)
By typing your full name here, you are electronically signing this document.