Records Release Form

Fill out your form online or download a copy.

Record Release Form

Record Release Form

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 patient(s).
  • MM slash DD slash YYYY

Call The Office

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

Office Location

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