Welcome 750 Central Avenue Suite K, Dover, New Hampshire 03820 | 603-743-6000 Records Release/ Request I, First Name Last Name hereby authorize the release of my child’s or my own dental records to/from: Dover Pediatric Dentistry & Orthodontics750 Central Ave., Suite KCentral Commons Dover, NH 03820 Tel: (603) 743-6000Fax: (603) 516-5690 If releasing records to another office: To: (Office Name) Office Address: Print Name of Patient: Parent's Signature: Clear Date: / Month / Day Year Date Preview PDF Submit Should be Empty: