Lincoln County Dental
Records Release Request

Please fill out the following form so we can request your records.

I

herby request and authorize

Dentist Address:

Dentist Phone:

Dentist Email:

to disclose and provide copies of any and all clinical treatment records and information concerning my care to:

Lincoln County Dental
P.O. Box 243
Wiscasset, ME 04578
207-386-6600
frontdesk@lcdental.org

These records include but are not limited to personal patient information, medical and dental history, examination records, radiographs (x-rays), clinical photos, treatment plans, treatment records, referral and consultation recommendations, and reports and diagnostic models to their related materials. I expressly release from liability the above-mentioned person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.

Patient or Guardian Name

Patient or Guardian Initials

I herby request and authorize to disclose and provide copies of any and all clinical treatment records and information concerning my care, which is in the possession of this person/entity to: Lincoln County Dental P.O. Box 243 Wiscasset, ME 04578 207-386-6600 frontdesk@lcdental.org

Lincoln County Dental Records Release Request

I

herby request and authorize

Dentist Address:

Dentist Phone:

Dentist Email:

Lincoln County Dental
Records Release Request