Dental Records Request l MatchMyDentist

Welcome to our X-Ray Request Form!

To make your second opinion process seamless, this form will automatically notify your dentist to send your digital X-rays. Once received, follow the simple instructions on our site to securely upload them for review.

If you have questions or need help at any point, please contact our support team.

Patient Information Form

Patient Information

First Name	Last Name
Date of Birth	Gender Male Female
Email Address	Phone Number

Provider Information

Office/Provider Name	Office/Provider Email Address
Office/Provider Phone	Office/Provider Fax

Authorization for use/disclosure of medical and dental information

Authorization for Use/Disclosure of Information

I voluntarily consent to authorize my dental providers to use or disclose my dental information to the recipient that I have identified above:

DENTAL RELEASE Information requested

Copy of digital dental x-rays
Copy of Periodontal Chart
All treatment rendered

Authorization

I hereby authorize my dental provider to release my protected health information described above. I certify that this request has been made voluntarily and the information provided is accurate to the best of my knowledge. I understand that I can revoke this authorization at any time, except for actions already taken to comply with it.

Add Your Signature Here

I agree to the Terms & Conditions and Privacy Policy

Your data is secure and encrypted.

Welcome to our X-Ray Request Form!

Patient Information Form

Patient Information

First Name	Last Name
Date of Birth	Gender Male Female
Email Address	Phone Number

Provider Information

Office/Provider Name	Office/Provider Email Address
Office/Provider Phone	Office/Provider Fax

Authorization for use/disclosure of medical and dental information

Authorization for Use/Disclosure of Information

I voluntarily consent to authorize my dental providers to use or disclose my dental information to the recipient that I have identified above:

DENTAL RELEASE Information requested

Copy of digital dental x-rays
Copy of Periodontal Chart
All treatment rendered

Authorization

Add Your Signature Here

I agree to the Terms & Conditions and Privacy Policy

Your data is secure and encrypted.

Log in

Welcome to our X-Ray Request Form!

Patient Information

Provider Information

Authorization for use/disclosure of medical and dental information

Welcome to our X-Ray Request Form!

Patient Information

Provider Information

Authorization for use/disclosure of medical and dental information

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