Welcome to Chico Pediatric Dentistry!

Drs. Roos and Tornabene, DDS | 2775 Esplanade • Chico,CA 95973
(530)893-4044

AUTHORIZATION TO RELEASE DENTAL RECORDS

  • Last Name
  • First Name
  • Middle Name
  • Preferred Name
  • Patient Date of Birth
  • Address 1
  • Address 2
  • City
  • State
  • Zip Code
  • Home
  • Mobile
  • Work
  • Ext

THIS IS AN AUTHORIZATION TO RELEASE THE MOST CURRENT DENTAL RECORDS

  • Last Name
  • Address 1
  • Address 2
  • City
  • State
  • Zip Code
  • Phone:
  • Fax: