To have your child’s dental records and x-rays sent to you or a dentist/dental office for purposes of continuing dental care, please complete the below form.

This form can only be submitted by your child’s custodial parent or legal guardian. To protect your child’s privacy, dental records can only be sent to you as the custodial parent or legal guardian, or a dentist/dental office for purposes of continuing dental care.

For all other requests, please call 800-770-0388.


To the following dentist or dental office:


To the parent or guardian:

By submitting this document, you are acknowledging the risk that by sending this form the information provided may be intercepted and read by a third party. If you do not wish to accept this risk, please call 800-770-0388.