Southern Maryland Dental Society
4920 Niagara Road, Suite 306
College Park, Maryland 20740
301-345-4196
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PATIENT REQUEST FORM
Upon receipt of this completed form, a mediator will be assigned to discuss your request and help resolve the issue.
While a refund of the charges you have paid is one of the options that may be recommended by the mediator, a
request for a refund should not be made in writing.
PATIENT INFORMATION: (Please Print)
Date:                                                                                  Case No:
Name:
Phone: Home                                                      Office:                                    Cell:
Address:
City:                                                                             State:                             Zip:
NAME OF DENTIST: (Please Print)
Name:                                                                                  Phone:
Address:
City:                                                                             State:                          Zip:
Date of Last Appointment:
Please describe the problem(s) specific to the dental treatment received: (Please Print)
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Thank you for addressing your concerns to the Southern Maryland Dental Society.

Please provide a phone number below, and the best time of the day when the mediator will be able to
contact you. If you have any questions in the meantime, please do no hesitate to contact the Southern
Maryland Dental Society at 301-345-4196.

Please include you Day Time Phone No:_______________________________________________
and you Evening Phone No:__________________________________________________________

In order that a complete review be performed, I authorize the release, to this committee, of any dental
records or information by anyone who has examined me previously. I further give my permission for the
committee to perform a clinical examination, if necessary.

___________________________________________________________________________________
                           Signature