Doroschak Dental - Patient Forms

FIRST Name

LAST Name

MI

Please enter the information below so we can contact the dental office to request your records.

Previous DDS

Name of Your Previous Dentist

DDS Address

Street Address

Optional: Address Line 2

City

State/Province

Postal/Zip Code

DDS Phone Number

Please enter a valid phone number, including area code.

Please enter the information below about who's records we should request.

First Name

Last Name

MI

Birth Date

dd/mm/yyyy

To be sent to the office of:

DOROSCHAK DENTAL
230 BROADWAY STREET NE
MINNEAPOLIS, MN 55413
(612) 379-2300

Digital radiographs should be e-mailed to: [email protected]