Harmony Orthodontics | Records Request Form

Patient Information (CONFIDENTIAL)
Name*

First NameLast Name
Address*

Address

Street Address Line 2

CityState

ZIP
What is the best number we can reach you at (cell, work, home)
Please enter a valid phone number.
Additional family members to transfer
Previous Dentist/Dental Practice Information
Dentist/Dental Practice Name
Address
Phone Number
Authorization

I here by give permission and request to release any and all of my dental diagnostic/treatment x-rays to Harmony Orthodontics.
Signature

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Name of Parent/Guardian
Date

MonthDayYear
Date
If X-Rays are digitals, please send via email to: info@smileinharmony.com

Or mail to:

742 NE Division Street Suite 201 Gresham, OR 97030

37515 SE Hwy 26 Sandy, OR 97055

For additional information, please contact us at (503) 666-2196 or (503) 668-0320
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