We are happy to provide a copy of your records!

Please fill out the form below or call us if you need assistance, our team is ready to help you!

Please note patient care is our immediate priority, records requests come secondary and although we try to process these as soon as possible, we can take up to 5 days to process these requests.

We look forward to making orthodontics the BEST part of your day!

Patient Name *

First

Last

Date of Birth *

up to: Date

Patient Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email *

Phone *

ORTHODONTIC RECORDS INFORMATION

Please release my orthodontics records to:

Doctor/Clinic's Name

Please release my orthodontics records to:

Legal Guardian/Other. Note this person must present valid photo/government ID if picking up at the practice.

Records Requested

Initial/Progress/Final Photo & 3D Scan Layouts in JPEG Format (Sent via email, No charge)
Initial/Progress/Final Panoramic Radiograph in JPEG Format (Sent via Email, No charge)
3D CBCT sent digitally (Sent to Practitioners only via email link, No charge)
3D CBCT on USB ($35)-must be picked up at the office, we will contact you when ready
3D CBCT, Photo & 3D Scan Layout on USB ($35)-must be picked up at the office, we will contact you when ready

Send Records to this email address:

Make Records Available for Pick up at Front Desk

Contact me when available

Note, we will contact you when these are ready. Must be picked up within 7 days of our team contacting you. We will only release to the requester with valid photo/government identification.

Orthodontic Records Release Terms & Conditions *

I accept the terms & conditions

1. YOUR AGREEMENT

By agreeing to this release form, you agree to be bound by, and to comply with, these Terms and Conditions. If you do not agree to these Terms and Conditions, please do not use tick the box.

PLEASE NOTE: We reserve the right, at our sole discretion, to change, modify or otherwise alter these Terms and Conditions at any time. Unless otherwise indicated, amendments will become effective immediately. Please review these Terms and Conditions periodically.

By signing this form, you indicate that you have the legal authority to request and access these records and authorize us to send them to the person/clinic that you indicate via email or for pick up. You release Synergi Orthodontic Specialists and any associates/employees from liability in the process. While our practice does our absolute best to keep your data secure, you understand that sending records via email can never be fully secure and can be intercepted by a number of ways including but not limited to security breaches, typographical errors, etc. You understand that our practice can take up to 5 days from receipt of this form to send or prepare these records. Our first priority is patients scheduled in the office, so records requests come secondary to immediate patient care. I understand that if I request patient records and Synergi Orthodontic Specialists is unable to verify authorization based on the patient consent forms we have on file in our practice management system, that Synergi Orthodontic Specialists will not release the records.

Legal Authority *

I certify I have legal authority to request these records.

This must match our HIPAA/Consents on file.

Legal Guardian/Patient's Full Name *

Legal Guardian/Patient's Signature *

Clear Signature

Date *

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