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: NamePatient 1: DOB Patient 2: NamePatient 2: DOB Patient 3: NamePatient 3: DOB Patient 4: NamePatient 4: DOB Patient/Parent/Guardian Signature*Requested From:Office NameDoctor NamePhone NumberFax NumberStreet AddressCity, State, Zip This iframe contains the logic required to handle Ajax powered Gravity Forms.