Authorization for Dental Records
To Be Released From Boger Dental

Authorization for Dental RecordsTo Be Released From Boger Dental Form
Please provide the patient's name.
Required.
Required.
Required.
Please provide the patient's address.
Please provide a valid email.

I authorize Boger Dental to release my dental and medical information to:

Please provide the name of the clinic.
Please provide the phone number for the clinic.
Please provide a valid email for the clinic.
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Please enter your full name.
Required.
Required.
Required.

This is valid until you, as the patient, notify us of change

2720 Annapolis Circle N., Suite A, Plymouth, MN 55441
 | 763-546-7707 phone | 763-546-7713 fax | BogerDental.com