Form: Incoming Records Release Form

Patient Information

Records Release Authorization

Patient's Date of Birth:

I hereby authorize the release of records/xrays and request they be transferred to:

Kalamazoo Dental Associates

2131 Hudson Street

Kalamazoo, MI 49008

OR

Email: [email protected]

Patient or Legal Guardian/Authorized Representative

Sign Form

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.