Patient Information Form

Steven E. McComb, D.D.S.
Tony C. Jewett, D.D.S.
236 W. 3rd St.
Chico, CA 95928
Phone (530) 342-8314; Fax (530) 342-8362

Records Release

Date
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
EMAIL ADDRESS: chicodentalcare@gmail.com
Please forward any FMX and any recent check up X-RAYS, Thank you!
Print name of Patient:
Patient E-mail Address:
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