Authorization to Release Dental Records Patient's Name and Address Patient's Date of Birth Dentist's Name and Address I hereby request a release a copy my dental records and current x-rays to the dental office below: I hereby request a release a copy my dental records and current x-rays to the dental office below: ConsentIrish Dental Kevin Hardy D.D.S The Medical Pavilion 25 Hospital Center Blvd. Ste. 102 Hilton Head Island, SC 29926 Phone (843)689-5500 Fax (843)689-6600 Email: welcome@irishdentalhhi.comTyping in your name constitutes and electronic signature. First Last Contact Us Today! Name Email Address Message Submit Schedule An Appointment Irish Dental 25 Hospital Center Blvd #102, Hilton Head Island, SC 29926, USA
