Get Mn Mount Royal Dental Records Release Form 2015-2026

Filling out the MN Mount Royal Dental Records Release Form online is a straightforward process designed to help you authorize the release of your dental records. This guide provides clear, step-by-step instructions to ensure you complete the form accurately.

Follow the steps to complete the dental records release form online.

1. Click ‘Get Form’ button to obtain the form and open it in the editor.
2. Enter the patient’s name in the designated field. This should be the name of the individual whose dental records you are requesting.
3. Fill in the date of birth field to confirm the identity of the patient.
4. Input the patient's phone number for any follow-up communication regarding the records request.
5. Provide the name and phone number of the previous dentist or dental practice to assist in locating the records.
6. Complete the address section, including street address, city, zip code, and state of the previous dental practice.
7. Indicate whether the request applies to yourself or other family members by selecting the appropriate checkbox. If selecting 'Other Family', list the names of family members in the provided space.
8. Authorize the release of your dental information by confirming that you are requesting to have all dental information sent to Dr. Zelen at Mount Royal Dental. Make sure to note that you would like any current x-rays forwarded as well.
9. If the patient is a minor, a parent or guardian should sign in the patient signature field. Otherwise, the patient should sign in this area.
10. For digital records, ensure to include the email address, info@smileduluth.com, in the specified section.
11. Finally, enter the date on which you are signing the form.
12. Once you have completed all sections of the form, you can save your changes, download the document, print it for physical signing, or share it as needed.

Start filling out the MN Mount Royal Dental Records Release Form online today to manage your dental records effectively.