Dental Record Request

I hereby request the release of dental records of:

Patient's Full Name *

Patient's Date of Birth *

Patient's Full Address *

At which location of the247dentist was this patient seen? (use drop down box to select) *

Records being requested

Current radiograph(s)

Treatment notes/history

Itemised bill/invoice

Other (please specify):

I request for these to be emailed at the following email address: *

Name of person requesting records: *

Your relationship to the patient (use drop down box to select): *

Please note: If you're requesting records of a person who is 18 years or older, they must contact us by telephone to authorise to share their records with you.

Please upload a copy of your/ patient's proof of identity (e.g. driving licence, passport, national ID card, birth certificate, utility bill from the past 3 months showing patient name at the address we have on file). Please note that we cannot process your request without proving patient's identity. *Maximum 10MB

Dental Record Request

0330 175 9995

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