Select Page

Request Your Dental Records

Please complete the form below to request a copy of your dental records.

OR

Which office were you normally seen in? (required)

Please confirm how you'd like your records to be sent (required)

I hereby authorize Dental & Sedation Group, LLC and Dr. Laurence E. Fendrich, DMD to provide copies of my dental records with respect to any dental care and treatment I have received to the person(s) listed above and at the physical address or email address provided.

I understand that the specific type of information to be disclosed includes a detailed report of examinations, treatment provided, x-rays and all other records that pertain to me.

This consent is effective until such date as I can cancel this consent. I understand that the information obtained as a result of this consent may be used after the cancellation date.