Please take a moment to fill out this form so we may release your dental records.
I understand and agree to pay a reasonable charge to cover the costs of the transfer, as allowed in Health and Safety Code ss123100 et seq. and Evidence Code s1158.)
Note: to be valid, an authorization must be clearly separate from other language on a page and executed by a signature, which serves no purpose other than to execute the authorization. It can either be handwritten by the person who signs it or in typeface no smaller than 8 point.
$39.00- Duplicating fee for x-ray request/ $50.00 for chart copy request/ $50.00 for each copy of orthodontic records request.