Get Signed Consent to Release Dental X-Rays and Records

Let patients authorize the release of dental X-rays and treatment records, capturing the recipient, purpose, delivery method, and expiration in one form.

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Dental Office Patient X-Ray & Treatment Records Release Authorization Form

Patient Full Name

· · ·

Patient Date of Birth

· · ·

Patient Phone Number

· · ·

Submit

This dental records release authorization form gives your practice a clear, organized way to get patient permission before sharing X-rays and treatment records. Patients enter their contact details, select which records to release, and specify treatment dates or leave the field blank to include all dates. They also state the purpose of the release. The form captures the recipient's name or dental practice, phone or fax number, email, mailing address, and preferred delivery method, so your team knows exactly where and how to send copies.

The template is ideal for general dentists, orthodontists, oral surgeons, pediatric dental offices, and multi-location dental groups. These practices often transfer records when patients relocate, switch providers, see a specialist, or need documentation for insurance claims. Front desk staff and office managers can replace paper request forms, reduce phone tag, and keep every signed authorization organized in one place.

The built-in authorization statement explains key patient rights and practice policies. It covers the right to revoke in writing and confirms that treatment will not be conditioned on signing. It also notes that redisclosed information may no longer be protected by HIPAA, that original X-rays stay with the practice and only copies are released, and that a reasonable, cost-based copy fee may apply. Patients choose when the authorization expires. Representatives signing on a patient's behalf can provide their name, relationship, and photo ID or proof of authority. Customize the wording to fit your office policies and state requirements, then start processing record requests faster.

3 Pages

19 Questions

~6min To complete

Free No credit card needed

Field types Date ×2 Phone ×2 Email ×2 Address ×2 Dropdown ×2 Short Text ×2 Full Name Multiple Choice daterange Single Choice File Upload termsandconditions Signature

Questions in this template

Free template

The exact questions included — customize any of them to fit your needs.

Page 1 Patient Information 5 questions

Patient Information

1 Patient Full Name * Full Name

2 Patient Date of Birth * Date

3 Patient Phone Number * Phone

4 Patient Email Address * Email

5 Patient Mailing Address * Address

Page 2 Records & Recipient Details 8 questions

Records & Recipient Details

1 Records to Be Released * Multiple Choice

2 Treatment Dates to Include (leave blank for all dates) daterange

3 Purpose of Release * Dropdown

4 Recipient Name or Dental Practice * Short Text

5 Recipient Phone or Fax Number * Phone

6 Recipient Email Address Email

7 Recipient Mailing Address * Address

8 Preferred Delivery Method * Dropdown

Page 3 Authorization & Signature 6 questions

Authorization & Signature

I authorize this dental practice to release the dental records I have selected to the recipient I have identified, for the purpose stated in this form. I understand that I may revoke this authorization at any time by providing written notice to the practice, except to the extent that action has already been taken in reliance on it. My treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. Information disclosed under this authorization may be redisclosed by the recipient and may no longer be protected by federal privacy law (HIPAA). Original X-rays and records remain the property of the practice, and only copies will be released. A reasonable, cost-based copy fee may apply as permitted by law, and I am entitled to a copy of this signed authorization. This authorization will expire on the date or event selected below.

1 This Authorization Expires * Single Choice

2 Representative Name & Relationship to Patient (if signing on patient's behalf) Short Text

3 Photo ID or Proof of Representative Authority File Upload

4 Today's Date * Date

5 I have read and understand this authorization, confirm that the information provided is accurate, and voluntarily authorize the release of the dental records specified in this form. * termsandconditions

6 Signature of Patient or Authorized Representative * Signature

How to use this template

Click "Use This Template Free" to open it in the FormBuilder editor. From there you can add, remove, or reorder fields with drag-and-drop, switch themes for instant restyling, add your logo, configure email notifications, and set your success message. When ready, publish with a unique link and start collecting responses immediately.