Record Request Consent

The office of Christine M. Coats DDS has my permission to obtain the necessary radiographs and/or treatment notes and records for the following patients:*
- I Agree
Date (mm/dd/yyyy)
Patient 1: Name
Patient 1: DOB
Patient 2: Name
Patient 2: DOB
Patient 3: Name
Patient 3: DOB
Patient 4: Name
Patient 4: DOB
Patient/Parent/Guardian Signature*
Requested From:
Office Name
Doctor Name
Phone Number
Fax Number
Street Address
City, State, Zip

Requested From: