Records Release Form | Dover Pediatric Dentistry

750 Central Avenue Suite K, Dover, New Hampshire 03820 | 603-743-6000

I,

First Name Last Name

hereby authorize the release of my child’s or my own dental records to/from:

Dover Pediatric Dentistry & Orthodontics
750 Central Ave., Suite K
Central Commons Dover, NH 03820

Tel: (603) 743-6000
Fax: (603) 516-5690

If releasing records to another office:

To: (Office Name)

Office Address:

Print Name of Patient:

Parent's Signature:

Clear

Date:

Date

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