Record RequestRecord ReleasePatient, Parent or Legal Guardian* First Last Patient Name if Minor First Last Patient Date of Birth MM DD YYYYAddress Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email PhoneConsent I hereby authorize Dr. Carrie Reddish’s office to release copies of protected dental information of the above-named patient to the following person or facility: * Name of the Person or Facility Address of the Person or Facility City State ZIP / Postal Code Phone Number of the Person or Facility*Email of the Person or Facility* Reason for Record ReleaseDentist closer to homeMovedDate* Signature*Please make sure to click SUBMIT before advancing to the next page