CHILDREN'S DENTISTRY OF WESTERLY RI & WAKEFIELD RI

Medical Records Release Form

Your Information:

First Name

Last Name

Phone

Address

Address 2

City/Town

State

Zip Code

Child(ren) whose records are to be released:
For more than four children, please contact our office directly.

Child's Full Name

Child's DOB

Child's Full Name

Child's DOB

Child's Full Name

Child's DOB

Child's Full Name

Child's DOB

Doctor/Office Awaiting Records:

Doctor's Office - Recipient Name for Records

Office Phone

Email Address for Secure Email

Office Address

State

Zip Code

Acknowledgment:
Please check off the required acknowledgment statement below before submitting this form.

I certify that the information provided in this form is correct to the best of my knowledge. I also certify that I am the person who I claim to be and I am not falsely representing another individual.

Signature

When should I schedule my child’s first dental visit?

As soon as your child has teeth, there is potential for tooth decay! Schedule your child’s first dental visit with us by his/her first birthday or within 6 months of the first tooth erupting. We’re your top Rhode Island pediatric dentists located in Westerly, RI & Wakefield, RI, caring for Rhode Island and southeastern Connecticut families. We accept most insurance plans in both offices, including:

Contact Children's Dentistry of Westerly & Wakefield

Reason

First Name

Last Name

Phone

Message

Dentist in Westerly RI | Dentist in Wakefield RI | Rhode Island Pediatric Dentists | Southeastern Connecticut Pediatric Dentists

CHILDREN'S DENTISTRY OF WESTERLY RI & WAKEFIELD RI

Medical Records Release Form

Contact Children's Dentistry of Westerly & Wakefield

Children’s Dentistry – Westerly, RI

401-596-8720

Children’s Dentistry – Wakefield, RI

401-792-4664

© Copyright 2024 Children's Dentistry of Westerly & Wakefield - All Rights Reserved.

Referrals

Schedule An Appointment at Children's Dentistry of Westerly and Wakefield