Dental Records Release Form
Robin Asbury D.D.S.
9025 E. Mineral Circle, Suite 102, Centennial, 80112
3195 W. 35th Avenue, Denver, 80211
(303) 768-8443


I hereby authorize the release of my digital dental radio-graphs and periodontal charting to the following Recipient:

Recipient Email Address: *
What is the email address of where your dental records need to be sent?
Your answer
Patient Email Address: *
What is your email address?
Your answer
Printed Patient Name: *
Your answer
Date of Birth: *
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Signature: *
Please type your name below, making sure to accept the terms and conditions.
Your answer
Terms of Acceptance: *
I warrant the truthfulness of the information provided in this application. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance.
Required
Date of Signature: *
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For any and all questions, please contact our office at (303) 768-8443.
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