Dental Records Transfer Request

Patient Full Name

First NameMiddle NameLast Name

Date of Birth

Date

Preferred Contact Method

Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Email Address

example@example.com

Current Mailing Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Current Dental Provider or Practice Name

Provider Phone Number

Please enter a valid phone number.Format: (000) 000-0000.

Provider Email or Fax Number

Approximate Dates of Treatment or Last Visit

Reason for Records Transfer Request

Transfer Urgency

Records Requested

Treatment Period Start Date

Date

Treatment Period End Date

Date

Preferred Delivery Method

Delivery Address

Street Address

Street Address Line 2

CityState / ProvincePostal / Zip CodeCountry

Special Handling Instructions for Receiving Office

I understand that this authorization applies only to the records and recipient listed in this request.