Dental Records Request Form

Request For Dental Records to be sent to:

St. Mary’s Dental
Gina F. McCray, D.D.S., P.A.
28160 Old Village Road
Mechanicsville, MD 20659
301‐884‐3248

I, , authorize to furnish a copy of dental records to St. Mary’s Dental for the following Patients:

Name:

Date of Birth

I release you from legal responsibility or liability that may arise from this authorization. Thank You!

Previous Dentist Name and Address:

Previous Dentist Phone #:

Please email digital radiographs to scheduling@stmarysdental.com or mail radiograph copies to:

St. Mary’s Dental
Attn: Gina McCray, DDS
28160 Old Village Road
Mechanicsville, MD 20659

FAX: 866‐219‐6469

Patient Signature or Parent or Guardian Signature (if patient is a minor):

Date:

Thank you for giving us the opportunity to serve you and your dental needs. If you have any questions about this form please let us know.