prescottfamilydental.com - Release of Records Form

RELEASE OF RECORDS AUTHORIZATION
What is your previous dentist's name/practice name?
What is your previous dentist's address?
What is your previous dentist's phone number?
Please enter a valid phone number.
What is your previous dentist's email address?
example@example.com
What is your new dentist's name/practice name?
What is your new dentist's address?
What is your new dentist's phone number?
Please enter a valid phone number.
What is your new dentist's email address?
example@example.com
RELEASE OF RECORDS AUTHORIZATION
By signing below, I consent for my dental treatment records and/or x-rays to be transferred by email to info@prescottfamilydental.com.

Practice Name: Prescott Family Dental

Practice Address: 1015 Campbell St N, Prescott, WI 54021

Practice Phone number: (715) 262-3382
Patient's Signature:

Clear
Date:

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Date
RELEASE OF RECORDS AUTHORIZATION

By signing below, I consent for my dental treatment records and/or x-rays to be transferred by email.
Patient's Signature:

Clear
Date:

MonthDayYear
Date
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RELEASE OF RECORDS AUTHORIZATION