Record Release Request

  • MM slash DD slash YYYY
  • 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]

  • MM slash DD slash YYYY
  • This field is for validation purposes and should be left unchanged.