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Request Your Records

Complete the secure form below to request a copy of your dental records. Once submitted, please allow 10 business days to process your request. Prefer a paper form? Download the PDF.

Secure Online Form

Release Authorization

Your information is sent directly and securely to our office — we do not store it on any external server.

Patient Information

Patient Name (as shown on records)

Date of Birth

Relationship to Patient

Records Requested

Complete recordSpecific time periodSpecific portion / type of record

Minor PatientThis request is for a minor patient (under 18)

How Would You Like to Receive Your Records?

Pick up in officeMail to address

Name of person picking up

Patient / Authorized Representative Signature

Authorization & Consent

I authorize Beechmont Family Dental to release the records described above. I understand this authorization may be revoked in writing at any time, except where action has already been taken on it.

I consent to submitting this authorization electronically and understand that my digital signature has the same legal effect as a handwritten signature.

Your information is transmitted securely and sent directly to our office. We do not store PHI on any third-party server.