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

Patient Information
Please provide the patient's name.
OK!
Please provide the patient's address.
OK!
(mm/dd/yyyy)
Please provide the patient's date of birth.
OK!
Please provide a valid email.
OK!
Previous 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 email digital records to: records@bogerdental.com

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