South Airdrie Smiles
Email : info@southairdriesmiles.com
Request for Release of Records from Previous Dentist
Previous Dentist Information
Dentist Name
First Name
Last Name
Dental Practice Name
*
Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Email Address
example@example.com
Patient Information
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
-
Month
-
Day
Year
Date
Patient Phone Number
*
Please enter a valid phone number.
Format: (000) 000-0000.
Additional Family Members
Family Member #1
Family Member #1 Name
First Name
Last Name
Family Member #1 Date of Birth
-
Month
-
Day
Year
Date
Family Member #1 Relation
Family Member #2 (if applicable)
Family Member #2 Name
First Name
Last Name
Family Member #2 Date of Birth
-
Month
-
Day
Year
Date
Family Member #2 Relation
Family Member #3 (if applicable)
Family Member #3 Name
First Name
Last Name
Family Member #3 Date of Birth
-
Month
-
Day
Year
Date
Family Member #3 Relation
Family Member #4 (if applicable)
Family Member #4 Name
First Name
Last Name
Family Member #4 Date of Birth
-
Month
-
Day
Year
Date
Family Member #4 Relation
Family Member #5 (if applicable)
Family Member #5 Name
First Name
Last Name
Family Member #5 Date of Birth
-
Month
-
Day
Year
Date
Family Member #5 Relation
I authorize the previous dental practice listed above to release the following dental records for myself, and those named above:*
Yes
N0
Date
-
Month
-
Day
Year
Date
Last Appt Date
Treatment History (Complete Oral Exam)
Treatment History (Recall Exam)
Treatment History (Hygiene/Scaling)
X-Rays (Bitewing)
X-Rays (Full Mouth)
X-Rays (Panorex/Panoramic)
Any additional medical history, dental history, test results, photographs and/or radiographs (upon request by the dental practice)
Type a question
: Please ensure that all the requested information is provided to Confluence Dental upon submission.
Email : info@southairdriesmiles.com
Submit
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