Release Form

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

Phone

This field is for validation purposes and should be left unchanged.

Patient's Name(Required)

First Last

Today's Date(Required)

Practice Requesting Films From:

Email of Practice

Fill out the email address of the practice releasing/requesting information.

Practice Phone Number

I authorize the above dental practice to release my records. Please forward any radiographs and chart notes to:

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.

First Last

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