Patient Records Access Request Form
Dr. Gerilyn Alfe DMD
2704 N. Halsted St.
Chicago, IL 60614
Phone: 773-348-2704
Fax: 773-348-6772
I hereby request a copy of my dental record as detailed below.
- Full dental record held by this office
- Dental record for the period ______________ through ______________
- Copy of x-rays
- A specific portion/section of the record as follows:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Forward my dental records to:
________________________________________________________________________________________________________________________________________________________________________________________________________________________
Patient Name: ___________________________________________________________
Name: _________________________________ Relationship: ___________________
(If Different From Above)
Signature: __________________________ Date: __________________________
