Belleville Record Release Form

Patient Record Release Form

Please fill out the form below to allow us to access your records from another dentist.
Previous Dentist's Name*

First NameLast Name
Please enter the city (or address if you know it) of your previous dental office. *
Patient's Name*

First NameLast Name
Attention, {previousDentists}

I, {patientsName}, authorize the release of all medical and dental records on file in your office to Family Dental Centre.

Please provide the following:
- Previous treatment history
- Most recent Panoramic Radiographs; and
- Current PA's and Bitewing Radiographs.
Last recall: ________________________________________

Initial exam date: ___________________________________

Last scaling/polish: __________________________________

Last x-rays taken: ___________________________________

For the patients listed below this text.

Please e-mail x-rays to belleville@familydentalcentre.com.

Thank you for your prompt attention!
List of all patients whose records should be released:*
Do you consent to your previous dentist releasing your records to Family Dental Centre?*

I consent to my previous dentist releasing my records to Family Dental Centre.
Patient/Guardian Signature*

Clear
Date*

DayMonthYear
Date
Family Dental Centre Belleville

110 North Front St, Belleville, ON

Phone: 613-961-7050

Fax: 613-961-7937

belleville@familydentalcentre.com
Should be Empty:

Patient Record Release Form