Amy Moody, DDSVista Ridge Dental Arts Studio108 West Tenth Avenue, Johnson City, TN 37604Phone: 423.979.1800Email: info@vistaridgedentalartsstudio.comRequest for Dental Records Leave this blank Patient Name: * DOB: * Patient Email Address: Dentist Name: * Dentist Address: Dentist Email Address: Dentist Phone Number: Date of Last Visit: Please release my dental records and x-rays, in JPEG format to: info@vistaridgedentalartsstudio.com Vista Ridge Dental Arts Studio 108 W. 10th Avenue Johnson City, TN 37604 I authorize release of my dental records and x-rays to Vista Ridge Dental Arts Studio. Patient digital signature: * Date: * Submit Records Release Form
