Form

Patient Record Release Form (Transferring from our office to another office)

I am authorizing the copy and release of the dental records and most recent radiographs of the following patients (please check off one for each person necessary and include date of birth):

First Name

Last Name

Date Of Birth

DENTAL RECORDS RELEASE FORM

How would you like your records delivered?

If you selected Email or Mail, please write the email or regular address of the location you want them sent to, please include the name of the potential dental office.

Address

City

Zip Code

Patient/Legal Guardian Signature

Date

Exit survey

If you are transferring to an office for any reason besides moving to a different location, please answer the following questions(they are optional but we strive to improve our office and would highly value your opinions about our practice).

What do you believe our practice is doing well?

What were some of the deciding factors in your decision to transfer out of our practice?

Are there any additional comments you would like to make?