(*) indicates a required field.Patient Name* Date* MM slash DD slash YYYY I hereby state that I have requested the release of the medical radiographs and/or other records of:Name* which are currently the part of the patient record files held by Kids Healthy Teeth. I acknowledge the release of the aforementioned records and associated documents to:Name* Signature(Please use your mouse or finger on a touchscreen to sign in the box.)Signature* Reset signature Signature locked. Reset to sign again Printed Name* Witnessed By* Reset signature Signature locked. Reset to sign again Printed Name of Witness*
