Click on Calendar, type the year 'YYYY' and pick the month & date.
Request for Release of Information
Print blank form to fill by hand


  Last name

  First name

  Mid name
*Address:
City
State
Postal
APT#
* I hereby authorize Dr Robertson & Dr Redd Dental Health to obtain the information or records from
for the following patients:
Bitewings
PA’s
Panorex
Study Models
Probing Charts
Full Chart

*Signature :
Date :
(Your digital signature (full name) is as legally binding as a physical signature.)