Record Release Request

If you require your dental records to be sent to an individual or other health office, please fill out the request form below. The information that may be released would include, but not limited to, dental records, appointment information, and treatment information. Alexandria Children's Dentistry cannot control how the recipient uses or shares this information, and laws protecting its confidentiality at our office may or may not protect this information once it has been disclosed to the recipient. Information will not be released without a valid signature from the patient (or patient's guardian). This authorization will take effect from the signature date and remain in place until you cancel the authorization in writing.

Record release requests will take 2 weeks to process.

If you do need records sent sooner, please call our office. Our front desk team will be happy to accommodate your needs. 

Bold Fields are required.

Patient's Name: First and Last Person requesting the records for above patient: First and Last Relationship to Patient: Please Select OneMotherFatherLegal GuardianOther

If other provide name: First and Last

If the person requesting records is anyone other that mother or father, please submit credentials to info@lovekidsteeth.com after completing this form. Thank you!

Email on file:
Phone: Records Request $15.
School Form Request $10.

Type of Request:

X-rays only List of clinical services completed Clinical visit report and findings

Reason for request:

Method of records release:

Email - Encrypted email of the records to another dental office or service provider. Please provide email below. Email - Encrypted email of the records to another dental office or service provider. Please provide email below. Printed - In person pick - up. Printed - Mailed via USPS to address on file unless details provided below. This is the LEAST PREFERRED method of releasing the dental records. If this route is absolutely necessary, we require that the records be mailed with signature confirmation upon delivery.
There is an additional processing charge of $15.

Encrypted emails cannot be forwarded. Please provide any additional emails so that we can send records directly to each address.:
Total Charges related to above selections.: Please add the amounts from fees listed in 'type of request' and 'method of records release' sections. If applicable, a payment link will be sent to you.

Authorization for the Release of Protected Health Information

Only a parent or a legal guardian can request or consent to sharing of patient records. Please allow 3-5 business days for processing your request. This authorization is only applicable for services selected above and only upto the date of request. Any additional request for release of protected health information will require a separate authorization. Authorizing the disclosure of this healthcare information is voluntary. Once the information has been released according to the terms of this authorization, the information cannot be recalled.

---

Submit