mainepedo.com - Record Transfer

Record Transfer
I, (Parent/Legal Guardian) , authorize Southern Maine Pediatric Dentistry to release dental records and x-rays concerning Patient’s Name & Patient’s DOB to:
Clinic/Doctor Name/Other
Address
Reason for request
I understand that the dental records maintained by Dr. Whitney Wignall may contain dental and administrative information from other healthcare providers. I also understand that the practice of Dr. Wignall may charge a copy fee for the duplication of x-rays and records.

This authorization shall remain in effect until revoked by me in writing. All prior authorizations, if any, are hereby cancelled.
Signature of Parent/Legal Guardian

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Date

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Address
Phone Number
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Witness Signature

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Date

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Date
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