Amy Moody, DDS108 West Tenth Avenue, Johnson City, TN 37604Phone: 423.979.1800Email: info@vistaridgedentalartsstudio.comRequest for Dental Records Release Leave this blank I request my xrays/records to be released from Vista Ridge Dental Arts Studio, to the dental practice listed below or to myself at the below email address. Patient Name: *Can list all family members if this request is for the entire family DOB: * If multiple family members are included on line above, only signing member DOB required Email address: * Dental Practice: Email address: Appointment Date: Please allow 2 business days for this request to be fulfilled. I request my xrays/records to be released from Vista Ridge Dental Arts Studio, to the dental practice listed below or to myself at the below email address. Patient/parent signature: * Date: * Submit Request for Dental Records Release
