www.mountroyaldental.com - Consent to Release / Request Dental Records Form

Consent to Release / Request Dental Records
Patient Name*

First NameMiddle NameLast Name
I Type* , Consent and authorize Dr. Please enter Doctor's Name* to release my current and previous dental records, including any information from other dental practitioners, to Dr. Sam Gupta, DDS.
All recent x-rays including BW's, Panorex, FMX/PA's
Date of last recall / recare examination

MonthDayYear
Date
Date of last Scaling

MonthDayYear
Date
Copies of Periodontal charting
Recall Interval

6 Months9 Months
Scaling interval recommended

3 Months4 Months6 Months9 MonthsAnnually
Other concerns or comments
Signature ( Patient, Parent / Guardian)*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty: