DDA Records Release Request

Records Release Request

I hereby authorize and request for my dental records to be released to:
Downtown Dental Associates, LLP
1221 SW Yamhill Street, Suite 310
Portland, OR 97205
Phone: 503-227-0958
Fax: 503-222-4685
Email: info@ddaportland.com

Date

Patient Name

Patient Address

Please include:

FMX‎ Panoramic‎ BWX‎ PAs‎ Cone Beam‎ Periocharting‎ Chart notes‎ Date of last prophy‎ Date of last root planing/quads‎ Date of last periomaintenance‎ Date of last evaluation‎

I hereby release any liability related to the disclosure of this confidential and privileged information.

Signature

Clear

Date