RECORDS RELEASE REQUEST

DATE				

DENTIST or  OFFICE NAME								

ADDRESS											

CITY						STATE	ZIPCODE			

PHONE					FAX						

I AUTHORIZE THE RELEASE OF DENTAL RECORDS RELEVANT TO DENTAL TREATMENT, OR COPIES OF SUCH, INCLUDING XRAYS, CHART NOTES, AND PERIO AND RESTORATIVE CHARTING TO:

Abbott Family Dentistry, LLC
Robert P. Pierson, D.D.S.
1601 Abbott Road, Suite 102 ~ Anchorage, Alaska  99507
Phone (907) 336-8478  - Fax (907) 336-8873

               or E-MAIL TO:   ak907dentist@aol.com

NAME								DOB			

SIGNATURE							DATE			
(PATIENT, PARENT OR GUARDIAN)

PLEASE LIST ANY DEPENDENTS THAT YOU WOULD ALSO LIKE TO HAVE THEIR RECORDS TRANSFERRED TO OUR OFFICE:

NAME								DOB			

NAME								DOB			

NAME								DOB			

NAME								DOB			

NAME								DOB			

NAME								DOB