Thank you for choosing our office for your child’s dental care. All information in this form are kept confidential.

  • (*) indicates a required field.
  • Date Format: MM slash DD slash YYYY
  • I hereby state that I have requested the release of the medical radiographs and/or other records of:
  • 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:
  • Signature

    (Please use your mouse or finger on a touchscreen to sign in the box.)