Records Release Form

Fill out your form online or download a copy.

Sally Young, DMD & Cecil B. Bray, DMD Records Release Form

2 Lester Court Statesboro, GA 30458-2118 (912) 489-1386 office@brayandyoung.com

"*" indicates required fields

Name*

First Last

Date of Birth*

Email

I authorize the release of xrays and other dental records for the following patients:

From Dr.

Phone*

Date

Signature*

Please send or email current xrays (bitewings, periapicals less than one year old, panorex less than 5 years old) and any other information that would be beneficial in treating the above patient(s).

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Pay Online

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Call The Office

(912) 489-1386
Fax: (912) 764-8533

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Office Location

2 Lester Court
Statesboro, GA 30458
Located across from Statesboro High School.

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Email Us

office@brayandyoung.com