Record Release Request Date: MM slash DD slash YYYY To:Address: Street Address City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Telephone:Fax:I authorize the release of dental and medical records relevant to dental treatment, or copies of such and request that they are transferred to: Dr. Todd A. Gifford Gifford Family Dentistry 1616 SW Sunset Blvd. Suite E Portland, Oregon 97239 Telephone: (503) 246-1710 Fax: (866) 339-7503 Please send digital radiographs and records to: [email protected] Patient Name:Date of Birth: MM slash DD slash YYYY SIGNATURE OF PATIENT (or guardian):Consent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.*CAPTCHACommentsThis field is for validation purposes and should be left unchanged.
