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Request Dental Records

You can request that your child’s dental records and X-rays be sent to you or to a dentist/dental office if more dental care is needed. To protect your child’s privacy, we can only send dental records to the custodial parent or legal guardian or to a dentist/dental office for purposes of continuing dental care.

Child's Name *

Name of School *

City *

State *

Date of Service *

Date of Birth *

To the following dentist or dental office:

Dentist/Office Name *

Dental Appointment Date *

Address *

City *

State *

Zip *

Telephone *

Dental Office Email *

To the parent or guardian:

Guardian's Name *

Address *

City *

State *

Zip *

Telephone *

Parent Email *

By submitting this document, you are acknowledging the risk that by sending this form the information provided may be intercepted and read by a third party. If you do not wish to accept this risk, please call 855.469.7473.

For all other requests, please call 855.469.7473.