MeckDental Records Release Form

MeckDental Records Release Form
I, First Name* Last Name* (parent, legal guardian) hereby authorize and request the release of dental records and/or x-rays taken of my child to:
Patient's Name:
Patient's Date of Birth:
Address:

Street Address

Street Address Line 2

City/StateState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Release to: (chose one)
Dentist / Dental Office Name
Address:

Street Address

Street Address Line 2

City/StateState / Province

Postal / Zip Code
Phone:
Format: (000) 000-0000.
Email Address:
example@example.com
By selecting Digital Copy, you take full responsibility that the private dental records are going to be sent over the Internet without security and the ability to verify that receiving party successfully obtained the files. Furthermore, there is an understanding that the file format may not be compatible. We issue all x-rays in JPEG format. I understand that the X-rays are part of the original dental records that belong to Meck Dental. We require 72 hours from the time of signature to process your request. Please not that this form MUST be filled fully including your Signature, Date & Time, and the Phone Number that matches your original number when originally given to the practice. Please email the completed form to dental@mecknc.gov.
Parent/Guardian Signature:
Date and Time of Request
ID of Parent or Legal Guardian
Contact Number:
Format: (000) 000-0000.
Reason For Release:
Should be Empty: