Records Release Form

Fill out your form online or download a copy.

Record Release Form

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

2 Lester Court Statesboro, GA 30458-­2118 (912) 489­-1386

"*" indicates required fields

Date of Birth*
MM slash DD slash YYYY
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).

Call The Office

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

Office Location

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