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ImmediaDent Records Request
Please complete the form below to request your records, all records will be sent to your email and you can provide to whomever will need them. May take up to 30 days to process request.
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First and Last Name
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Your answer
Date of Birth
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MM
/
DD
/
YYYY
Email Address
*
Your answer
Phone Number
*
Your answer
What office were you seen at?
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Your answer
Reason for Requesting Records
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Your answer
Relationship to Patient
*
I am the patient
Patient is my child
Digital Signature - By typing your name below and clicking on “I Agree” below, you acknowledge and agree that all information above is your personal information and that the person that is completing this form is legally permitted to obtain all records.
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Agree
Disagree
Signature
*
Your answer
If no email, what address should be we mail your records to?
Your answer
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