Record Release Request Date: MM slash DD slash YYYY To: Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest 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):CAPTCHANameThis field is for validation purposes and should be left unchanged.
