Form

Release of Records- to our office

I authorize the release of records relevant to dental treatment and request that they be transferred to the following office.

Dr. Venetia Laganis, D.D.S., M.S.

7767 Elm Creek Blvd., Suite 110

Maple Grove, MN 55369

Phone (763) 420-2610

Fax (763) 494-4390

info@drlaganis.com

Please list name(s) and date of birth for ALL patient whose records need to be transferred:

Patient's First Name

Patient's Last Name

Date Of Birth

Patient's First Name

Patient's Last Name

Date Of Birth

Patient's First Name

Patient's Last Name

Date Of Birth

Patient's First Name

Patient's Last Name

Date Of Birth

Dental Office Name

Dental Office Email

Address

City

Zip Code

Phone

Parent Signature

Date