If you do not wish to submit this form online, you can download a printable form (requires Adobe Acrobat®) and mail to:
Commerce Park Children's Dentistry & Orthodontics, LLC
4702 Main Street
Bridgeport, CT 06606
If you wish to submit this form online, you can fill out and online form and click submit.
If you have previous records that can be retrieved from another doctor, complete the Record Release Form.