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Lincoln County Dental
Records Release Request

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

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

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.

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