FDC 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, ______________ (previous dentist)

I, _______________, 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?
Patient/Guardian Signature
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