Patient records release

This request and authorization applies to: Most current FMX, PANO, BWX, PAs and Perio chart. This authorization does not expire.

Patient name

First Name

Last Name

DOB

YYYY

Name of previous dentist

Phone number of previous dentist

Signature

I request and authorize the release of healthcare information of the patient listed above. Type your full name to give permission for Dr. Moody's office to request your dental records from your previous dental office.