Records Release Authorization
Transfer records from Kind Kids Dental
Patient full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
Date
Please list the names and birth dates for ALL children with records to transfer
Please provide the name and location of the clinic(s) that you are either wanting us to send info to or get info from, including email address:
*
If you are leaving our practice, please provide a reason why. How can we do better?
Parent/guardian name
*
First Name
Last Name
Parent/guardian email
*
example@example.com
Parent/guardian signature
*
Continue
Continue
Should be Empty: