Charlotte Dentist » Request for Release of Dental/Medical RecordsRequest for Release of Dental/Medical RecordsRequest for Release of Dental/Medical Records Please note that it is important to fill in all the fields before submitting. Thank you.Section A: Patient giving consentName * Name Name Name Name Address * Address Address Address Address Address State/ProvinceAlabamaAlaskaArkansasArizonaCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming Address Email * Phone * SSN * If you are human, leave this field blank. Next