Authorization for Dental Records
To Be Released to Boger Dental

Authorization for Dental Records to be Released to Boger Dental Form

I authorize the release of my dental and medical information to Boger Dental.

Please provide the patient's name.
Please provide the patient's address.
(mm/dd/yyyy)
Please provide the patient's date of birth.
Please provide a valid email.
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
(mm/dd/yyyy)
Please provide the name of the clinic.
Please provide the phone number for the clinic.
Please provide a valid email for the clinic.

Please email digital records to: records@bogerdental.com

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