Accepting New Patients · All Major Insurances Accepted(770) 691-5051

Records Release Consent Form

This HIPAA-compliant form authorizes your previous dental provider to release your records to Merchant's Walk Dental. Please fill out all fields and sign below.

Patient Information

First Name *

Last Name *

Date of Birth *

Phone Number *

Email Address *

Home Address

Previous Dental Provider

Provider / Practice Name *

Provider Phone *

Provider Address

Consent Statement

I, the undersigned, hereby authorize the dental provider named above to release and transfer my dental records — including but not limited to x-rays, treatment notes, periodontal charts, and any other relevant documentation — to Merchant's Walk Dental, located at 1344 East Cobb Dr., Suite 100, Marietta, GA 30068.

I understand that this authorization is voluntary and that I may revoke it at any time by contacting Merchant's Walk Dental in writing. I understand that my records will be used solely for the purpose of continuing my dental care.

This form complies with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

I have read and understand the consent statement above and authorize the release of my dental records. *

Patient Signature *

Sign here

Date: July 7, 2026

Your information is protected under HIPAA and will only be used to process your records request.

Records Release Consent Form

Patient Information

Previous Dental Provider

Records Requested

Consent Statement

Patient Signature *