Clearwater Dental

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Monday - Friday 08:00 AM - 5:00 PMSaturday and Sunday - CLOSED 509.783.5000

info@clearwaterdental.com 5000 W Clearwater AveKennewick, WA

If you would like to authorize us to release your dental records from Clearwater Dental to another practice, you may either fill out and submit the form below, or print out the PDF form to fill out and bring to our office (or mail to: Clearwater Dental, 5000 W Clearwater Ave, Kennewick, WA 99336).

Release from ClearWater Dental (PDF)

I authorize Clearwater Dental to release the following dental information to the dentist or healthcare provider below. This includes all health care information, current full mouth, pano, bitewing xrays, and periodontal charting.

* Full Name of Patient or Legal Authorized Individual

* Birth Date

* Dentist or Healthcare Provider

* I understand that entering my name below constitutes a legal signature confirming that I have provided accurate and complete information to the best of my knowledge.

* First Name

* Last Name

* Date

Dental Record Release Form from Clearwater Dental

Release from Clearwater Dental