AUTHORIZATION FOR RELEASE OF DENTAL RECORDS TO:

  
Robert H. Stephenson DDS
700 Country Club Road
Eugene, Oregon 97401
541-343-8527 (Phone)
541-349-0510 (FAX)
 
Dr. *
Please email my records to Robert H. StephensonDDS. sj@stephensondds.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:
                             Thank you,
Patient Name
Date
Patient or Responsible Party Signature