Dental Record Release Form This page provides all Metro Smiles patients with a way to digitally fill out their dental records release forms. I hereby authorize the release of my digital dental radiographs and periodontal charting to the following Recipient: Metro Smiles P.C. Dr. Robin Asbury 8200 E. Belleview Ave., Ste 460E, Greenwood Village, CO 80111 (303) 768-8443 Recipient Email Address(Required)Please provide the email address of your new dental office. Patient Email Address(Required)What is the patient's email address? Patient Name(Required) First Last Date of Birth of Patient(Required) MM slash DD slash YYYY Signature(Required) Reset signature Signature locked. Reset to sign again Terms of Acceptance(Required)I warrant the truthfulness of the information provided in this application. I understand that checking this box constitutes a legal signature confirming that I acknowledge and agree to the above Terms of Acceptance. I agreeDate of Signature MM slash DD slash YYYY For any and all questions, please contact our office at (303) 768-8443.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
