Welcome to our Dental / Medical Release Form

Please fill out our form completely. We will contact you when your records are available to be picked up or mailed. Thank you.

DENTAL / MEDICAL RELEASE FORM
Last Name	First Name		Email		Today's Date
To: Fine Dentistry of Downtown Orlando P.A.
I hereby authorize and request you to release my records to:
	Name			Phone	Fax
	Address:
Patient Records to be released:
Reason for Records Release:
Please call me records are ready and I will pick them up.
Please mail to the above address.
Please check this box to acknowledge your request to release your records to the above party. Note: You will still be required to sign off on this form when you come into the office
	Patients Name or Legal Guardian				Date

Fine Dentistry of Downtown Orlando   |    429 N. Ferncreek Avenue Orlando, Florida 32803   |   407-898-1621
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