Release of Information - Burnsville

Release of Information - Burnsville

Patient Authorization for Release of Information


I herby authorize the release of my Child(ren)s Information:


Please forward to my home email.

I understand that Dentistry for Children will provide one copy of these records at no charge. If for any reason more than one copy of x-rays is needed; there will be a duplication fee.

Security Measure


Dentistry for Children & Adolescents

  • Edina Office - 7373 France Ave. S., Suite 402, Edina, MN 55435 Phone: 952-831-4400
  • Burnsville Office - 14050 Nicollet Ave., Suite 100, Burnsville, MN 55337 Phone: 952-435-4102
  • Eden Prairie Office - 6385 Old Shady Oak Road, Suite 150, Eden Prairie , MN 55344 Phone: 952-932-0920

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