Authorization To Release Patient Records

Print this form now if you want to complete the form manually and send it to our office.

You may also type in your answers and then print the form for your records at the bottom.

Send Files and Records to:

I hereby authorize the release and delivery of the above named patient's records and files, copies of the most recent dental x-rays, and a summary of the most current dental findings.

I hereby release my current dentist and dental practice from any liability related to disclosure of confidental or privileged information to the receiving dentist and dental practice named above.

If you want to print the completed page for your records, you must do so BEFORE you send us the form.

Copyright 2015, Curtis Marketing Group, Inc. Do not use without written permission from Curtis Marketing Group, Inc.


  • Curtis Group
  • 9402 November Dr
  • St. Joseph, MN 56374
  • Phone: 1-320-363-0210
  • Fax: 1-320-363-0218
  • Email: Email Curtis Group