Request Your Dental Records

Date (required)

Your Name (required)

Your Email Address (required)

Your Phone (required)

Name of new dentist OR your name if you'd like the records sent to you (required)

Address where records should be sent

OR

Email where records should be sent

Which office were you normally seen in? (required)
 Lighthouse Point Plantation Miramar

Please confirm how you'd like your records to be sent (required)
 Physical address provided Email address provided

Please provide any additional information or instructions

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.

 I agree and authorize the transfer of my dental records