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

Release to ClearWater Dental (PDF)

Please email records to info@clearwaterdental.com or mail them to 5000 West Clearwater Avenue, Kennewick, WA 99336

I authorize the previous dentist or healthcare provider below to release the following dental information to Clearwater Dental. This includes all health care information, current full mouth, panoramic, bitewing x-rays, and period 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 to Clearwater Dental

Release to Clearwater Dental