Serving Ames, ISU & Central Iowa Communities

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Dentistry At Somerset

Records Release Form

Records Release Form

  • I, hereby request and authorize
  • To disclose and provide copies of any and all clinical treatment records and information concerning my care, which is in the possession of this person or entity, to:

    Dentistry at Somerset, Jason Niegsch, DDS, FAGD

    2720 Stange Road / Ames, IA 50010

    Phone: (515) 268-0516 / Fax: (515) 268-9161

    Preferred Method Email: smile@DentistryAtSomerset.com

    These records include, but are not limited to: personal patient information, medical and dental histories, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models and other related materials. I expressly release from liability the above named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.
  • Date Format: MM slash DD slash YYYY
  • If transferring family, please use head-of-household name above and list other family members below: