AUTHORIZATION FOR RELEASE OF DENTAL RECORDS TO:
Robert H. Stephenson DDS
700 Country Club Road
Eugene, Oregon 97401
Please email my records to Robert H. StephensonDDS. email@example.com
Please include relevant chart notes, the most recent bitewing x-rays, full mouth set of x-rays or panoramic film, and periodontal charting.
Please include records for my family members:
Patient or Responsible Party Signature