Patient Information Form

STEVEN E. McCOMB, DDS
236 W. 3rd Street
Chico, CA 95928
(530)342-8314

Records Release

I,
was last seen for dental care at:
Doctor:
Phone Number:
Patient E-mail Address:
I, authorize the release of dental records relevant to dental treatment, or copies of such, and request that they be transferred to:
DOCTOR: STEVEN MCCOMB, DDS
ADDRESS: 236 WEST 3 RD STREET
CHICO, CA 95928
PHONE: (530) 342-8314
FAX: (530) 342-8362
EMAIL ADDRESS: chicodentalcare@gmail.com
Please forward any FMX and any recent check up X-RAYS, Thank you!
Print name of Patient:
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