Record Release Request Date(Required) MM slash DD slash YYYY Previous Dental Office(Required)Address(Required) Street Address Address Line 2 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 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's First Name(Required)Patient's Last Name(Required)Date of Birth(Required) MM slash DD slash YYYY
