Wolken Family Dental ST Louis Logo
 



8888 Ladue Road Suite 200

St. Louis, MO 63124
Phone: (314) 727-6676 Fax: (314) 721-0930
info@wolkendental.com
www.wolkendental.com

Dental Records Release Form

1
I Authorize my doctor to release my records including Bitewing X-Rays less than 12 months old, FMX or Panaromic X-Rays less than 36 months old to Dr. Wolken.
I Authorize Dr. Wolken, located at 8888 Ladue Road Suite 200, St. Louis, MO 63124 to release my records including Bitewing X-Rays less than 12 months old, FMX or Panaromic X-Rays less than 36 months to:
Electronic records are preferred and should be sent via e-mail to:
info@wolkendental.com

Printed records may be sent by postal mail to:
8888 Ladue Road Suite 200
St. Louis, MO 63124

Phone: (314) 727-6676 Fax: (314) 721-0930
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