Record Request in Needham, MA - Carrie Reddish, DMD, P.C.

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*

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