Records Release Form

Records Release Form

REQUEST FOR TRANSFER OF DENTAL RECORDS AND RADIOGRAPHS
Dentistry on Liverpool

info@dentistryonliverpool.com
Date*

MonthDayYear
Date
I, Patient Name* hereby request Dental Office Name* to release my dental records and radiographs to Dentistry on Liverpool.
Patient Name*

First NameLast Name
Signature*

Clear
Please provide the following information of your previous dental office:
Email*
example@example.com
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Should be Empty: