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Dental Records Release

Evergreen Dental

125 W Evergreen, #204 | Palmer | 99645

Patient's Name

Birthday

Email

I authorize Evergreen Dental to request my dental records and medical records relevant to dental treatment FROM:

Please email records to

I authorize Evergreen Dental to release copies of my dental records and medical records relevant to dental treatment and request they are transferred TO:

Date

Initials

Thanks for submitting!

Please allow 48 hours for records to be ready for delivery.
All records will be delivered electronically unless otherwise requested.

Contact Evergreen Dental Today

Phone

info@evergreendentalak.com

125 W Evergreen Avenue

Suite #204, Palmer, AK 99645

Wednesdy - Friday

10:00am - 5:00pm

© 2020 Evergreen Dental, LLC