Frankford 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 Name Last Name
Please provide the city of your previous dentist or address if you know it. *
Patient's Name *

First Name Last 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 frankford@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 *

Day Month Year
Date
Should be Empty:

Patient Record Release Form