Authorization for Dental Records
To Be Released From Boger Dental

Authorization for Dental RecordsTo Be Released From Boger Dental Form

I authorize the release of my dental and medical information to a new dental provider listed below

Patient Information
Please provide the patient's name.
OK!
Please provide the patient's address.
OK!
Required.
OK!
Please provide a valid email.
OK!
New Clinic Information
Please provide the name of the clinic.
OK!
Please provide the phone number for the clinic.
OK!
Please provide a valid email for the clinic.
OK!
Please enter your full name.
OK!
Required.
OK!
Required.
OK!
Required.
OK!

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