| 1233 Highland Ave, Needham, MA 02492

Record Request

- Record Release
Patient, Parent or Legal Guardian*
First Last
Patient Name if Minor
First Last
Patient Date of Birth
MM
DD
YYYY
Address
Street Address Address Line 2 City State ZIP Code
Email
Phone
Consent
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 Release
- Dentist closer to home
- Moved
Date*
Signature*
- Please make sure to click SUBMIT before advancing to the next page

Phone: (781) 444-2282 Fax: (781) 444-6237

1233 Highland Avenue Needham, MA 02492

Monday: 7:30AM - 5:00PM Tuesday: 7:30AM - 5:00PM Wednesday: 7:30AM - 5:00PM Thursday: 7:30AM - 5:00PM Friday: 7:30AM - 4:00PM

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