Records Release Request Form

Print Form

Records Release Request

Date:

To:

(Doctor/Physician)

Address:

City: State:

Fax: Phone:

I authorize the release of my most recent bitewing radiographs, and Panorex or Full
mouth series and my dental records.

Please email the digital images to info@drgiordano.net (if applicable)

Or contact:

Claire M Giordano, DDS
2171 Jericho Turnpike, Suite 115
Commack, New York 11725
Phone: 631-462-5757
Fax: 631-462-7993

Patient's Name Date of Birth

Patient's Signature

Patient Validation: