ImmediaDent Records Request
Please complete the form below to request your records, all records will be sent to your email and you can provide to whomever will need them. May take up to 30 days to process request.
First and Last Name *
Date of Birth *
MM
/
DD
/
YYYY
Email Address *
Phone Number *
What office were you seen at? *
Reason for Requesting Records *
Relationship to Patient *
Digital Signature - By typing your name below and clicking on “I Agree” below, you acknowledge and agree that all information above is your personal information and that the person that is completing this form is legally permitted to obtain all records. *
Signature *
If no email, what address should be we mail your records to?
Submit
Never submit passwords through Google Forms.
This form was created inside of Bright Tiger Dental. Report Abuse