Chet K. Gray DDS, Wesley D. Gray DDS

2701 Cuthbert Ave Midland , TX 79701

432-694-5741

Dental Records Release Form

Patient Name to transfer:

Date of Birth:

Phone number:

Other family members to transfer

Previous Dentist or Practice Name

Address

City/St/Zip

Phone number

Please forward any of the following information that you have: x-rays, probing depth chart, charting, and photographs to Gray Cosmetic and Family Dentistry.

I hereby give you permission to release any and all of my dental records to Gray Cosmetic and Family Dentistry.

Patient Signature

Use your mouse cursor or the tip of your finger to sign below

Date

Parent Signature

Use your mouse cursor or the tip of your finger to sign below

Date

Mail to:

Gray Cosmetic and Family Dentistry
2701 W Cuthbert
Midland, Texas 79701