Records Release Authorization
Transfer records from Kind Kids Dental
Patient full name
*
First Name
Last Name
Date of birth
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit 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 wanting us to send info to, including email addresses:
*
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: