Records Request Form | Snail Mail - SF Pediatric Dentistry

To request your child(ren)'s records be sent to you through USPS Certified Mail and to inactivate them in our system, please fill out the following form.

* Indicates required field

Child's Name *

First

Last

Child's Name *

First

Last

Child's Name *

First

Last

Note: We will be using restricted certified mail to send your child's records, meaning that the addressee must sign for the letter. We will address the envelope to the parents or guardians listed below. If you list two people, only one of you will have to sign for the letter, not both.

Parent / Guardian *

First

Last

Parent / Guardian *

First

Last

Please confirm your mailing address: *

Line 1

Line 2

City

State

Zip Code

Country

If your mailing address here is different from the one we have on file for you, we will give you a call to confirm.

Submit

Records Request
Snail Mail

Location & Contact

Hours

Records RequestSnail Mail

Location & Contact

Hours

Records Request
Snail Mail