ADH Release of Records Request

ALDERSHOT DENTAL HYGIENE

Transfer of Records Request
To Doctor: (Previous Dentist and Phone Number)

First Name Last Name
Phone Number
Please enter a valid phone number.
Name

First Name Last Name
This letter is to authorize the release of dental records and radiographs for the patient(s) named above.

Radiographs including Bitewing's, Pa's, Pan, and Full mouth series Patient chart including periodontal & full mouth charting
I blanks (your name) release you from all legal responsibility that may arise from this matter.
Signed

Clear
Dated

Month Day Year
Date
The professional misconduct regulations made under the Dentistry Act, 1991, speak to the tranfer of records and/or reports "within a reasonable time". It is the College's viewq that, in most cases, this should be accom- plished within one or two weeks of receipt of the request. RCDSO Practice Advisory on the Release and Transfer of Patient Records dated August 2007.
384 Plains Rd East, Burlington, ON L7T 0A4

Phone:(289)427-0220 Fax:(289)427-0219

office@aldershotdentalhygiene.ca

www.aldershotdentalhygiene.ca
Should be Empty:

ALDERSHOT DENTAL HYGIENE