ROBISON DENTAL, PC – PATIENT RECORD RELEASE FORM

Robison Associates values your time!  We are providing this Records Release Form for you to complete online and submit to our office prior to your visit.  This will save you time when checking in for your dental services.

You can also click on the green button to download, print and complete this form and bring it with you on your scheduled appointment date.

We look forward to seeing you soon and appreciate your business.

Robison Associates, P.C.
3235 Templeton Gap Road
Colorado Springs, CO  80907
719-630-7727
www. Robisondental.com

I request and authorize that the above-named doctor or health care provider to release the information specified below to Dr. Letha Robison. I understand that the information to be released includes information regarding the following condition (s):

AUTHORIZATION:  I certify that this request has been made voluntarily and that the information given is accurate to the best of my knowledge.  I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it.  Without my express revocation, this consent will automatically expire upon satisfaction of the need for disclosure, but in any event;

Clear Signature

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Contact Us Today!

Call us today at (719) 630-7727 or complete our contact form