Have your medical records released to Desert Villa Dental

Your Name (required)

Date of Birth (required)

Your Phone Number (required)

Your Email Address (required)

I Do Hereby authorize

Name of Dental Office

Their Mailing Address

Phone Number

Fax Number

To release my dental records to:

Desert Villa LLC
1055 N La Cañada Dr Suite 109,
Green Valley, AZ 85614

Patient Signature

Date Signed

Notes (Optional)