TRANSFER OF RECORD

TRANSFER OF RECORD
Date

MonthDay Year
Date
Dental Office:
Phone Number

Area Code Phone Number
Fax

Area Code Phone Number
Name*

First Name Last Name
Authorize Dr.*

First Name Last Name
I, {name} request and authorize Dr. {authorizeDr}, to transfer my dental records to Tansley Woods Dentistry.
PLEASE INCLUDE THE FOLLOWING (IF AVAILABLE):
Radiographs taken within the last 3 years.

Treatment notes (especially any major work that has been completed)
Date of:

MonthDay Year
Date
Last COE:
Last BW’s:
Last PAN:
Last Recall:
Last New Patient Exam:
Patient Signature:*

Clear
Should be Empty: