Chet K. Gray DDS, Wesley D. Gray DDS

2701 Cuthbert Ave Midland , TX 79701

432-694-5741

Confidentiality Release and Health Information
Gray Cosmetic and Family Dentistry

Patient Name
Phone
Email

CURRENT MEDICATION:

ALLERGIC TO:

CONSENT:

I give permission to the following name/names listed to have access to my records:

Signature

Use your mouse cursor or the tip of your finger to sign below

Date

© 2024 - American Dental Software All rights reserved.