Release Form Download PDF Request for Release of Patient RecordsDate*Patient Name(s)*Please Accept This Signed Request as My Authorization to Release and Transfer the above Mentioned Records to Dr. Malak of Peace Park Dental.DateType Your Name, This Constitutes a Legal Binding Release.Previous Dental OfficePhoneFaxThis Section to Be Completed by the Previous Dental Office and Would Be Greatly Appreciated – Please Return Asap.Date of Most Current Complete Oral ExaminationDate of Most Current Scaling AppointmentDate of Most Current PanorexDate of Most Current Complete Recall ExaminationDate of Most Current Bw'sDuplicates will be ForwardedYesNobyMailFaxEmailAny Additional Pertinent InformationThis Patient is scheduled for an appointment at Peace Park Dental onPeace Park Dental EmployeeThis Form has beenEmailedMailedFaxedOn DateUntitledUntitledOption 1Option 2Option 3SubmitThis field should be left blank