Patient Transfer Form

  • AUTHORIZATION FOR TRANSFER OF DENTAL RECORDS

  • to remit my dental records to the dentist indicated below.

  • right to review my records when necessary for the time I was under his/her care.

  • is no longer responsible for my future dental care or needs after 30 days from the date below.

  • Please enter the following information below:

  • Date Format: MM slash DD slash YYYY