Dental Records Release Form

Name of Patient:___________________________________________________
Date of Birth:____________________    Phone Number:________________________

Previous Dentist:_________________________________________________
Address:_________________________________________________________
City/St/Zip:_______________________________________________________
Phone Number:__________________________________________________

Please forward the following information (please circle all that apply):
•	Dental xrays
•	Perio charting
•	Charting
•	Current treatment plan
I hereby give you permission to release any and all of my dental records to Dr. Brent W. Casper D.D.S
_________________________________________                _____________________
Patient Signature (parent if a minor)                                      Date

Please email records to:  casperfamilydental@gmail.com
		or
Fax records to: (509) 946-0462