• Request For Records

  • Laurier Dental Centre

    500 Laurier Ave,

    Milton, Ont., Canada

    info@laurierdental.ca

    905 878 9882 (O)

    905 878 8415 (FAX)

  • Dear Dr. ,

    has/have recently become a patient/patients in my practice.

  • Would you kindly forward the following records:
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  • All of the above will be kept indefinitely should you require them in the future.

     

    Thank you.

  • Date
     / /
    2 digit month, 2 digit day, 4 digit year
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  • Should be Empty: