Form

Request for Release of Patient Records

THE UNDERSIGNED AND LISTED PATIENT HAVE HEREBY REQUESTED THE TRANFER OF SAID RECORDS FOR WHICH INFORMATION IS TO BE USED FOR

Reason for request:

Other:

First Name

Last Name

Date Of Birth

Records To/From

Other Provider/Office

Phone

Address

City

Zip Code

Canandaigua Smiles

Orthodontics and Pediatric Dentistry

229B Parrish Street, Suite 140
Canandaigua, NY 14424
Phone: (585)394-4058 Fax: (585)394-6108

PLEASE SEND TREATMENT HISTORY AND DIGITAL RADIOGRAPHS/IMAGES TO:

info@CanandaiguaSmiles.com

THE UNDERSIGNED ACKNOWLEDGES THEIR LAWFUL AUTHORITY TO REQUEST THE RELEASE OF PATIENT'S RECORD.

Patient/Legal Guardian Signature

Date