Requesting Patient Records

Patients 18 years of age are considered adults and therefore must request their own records.

First and last name of person requesting the records for above patient

If the person requesting records is anyone other that mother or father, please submit credentials to info@smilewonders.com after completing this form. Thank you!

Type of Request

Please provide any additional emails so that we can send records directly to each address.

Please add the amounts from fees listed in 'type of request' and 'method of records release' sections. If applicable, a payment link will be sent to you.

Authorization for the Release of Protected Health Information

Thank you! Your submission has been received!

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