Customizable Dental Medical Release Form Template

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Patient Name

First

Last

Date of Birth

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone

DENTAL MEDICAL RECORDS INFORMATION

I Hereby Request That My Dental Medical Records Be Released To:

Dentist/Clinic's Name

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Dental Medical Records Release Terms & Conditions

This is where we'd put your full terms and conditions for your release form. This field is marked as required and has to be ticked to be submitted.

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

Patient's Signature

Date

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Are you processing medical release forms for dental patients that visit your website? If so, then you need the Dental Medical Release Form Template from WPForms.

This form template comes pre-made with all of the fields and questions required of a medical release form, already in place.

Using the Dental Medical Release Form Template

While this form template includes the basic fields and questions found on medical release documents, it has been adapted for use in the dental field. So, it would be useful for dental clinics, orthodontics offices, hospitals, and other medical settings.

These are the fields that start off the Dental Medical Release Form Template:

Patient Name
Date of Birth
Patient Address
Email
Phone

With the patient information out of the way, the form then moves on to the dental medical record details. Form users will find these fields, next:

Box for requesting a records release to a dental clinic, etc.
Address
Checkmark to accept the terms and conditions
Patient’s signature
Date

The Dental Medical Release Form Template is a fairly universal form, and takes minimal editing to get you started. Simply add the details that are specific to your own organization, such as your own terms and conditions. You’ll be processing dental medical releases through your website in no time.

Get started with WPForms today to create and customize your own Dental Medical Release Form. Signing up with WPForms gives you access to this and hundreds of other pre-made templates.

Our form templates let you create any kind of WordPress form in a few clicks.

You can select any template to view the demo and try it out. If it works for you, you can import it and publish it in minutes. Each WPForms template is fully customizable too. Our drag and drop form builder makes it easy to adapt any template to fits your business’ needs. When you use our form templates, you can easily: