Form

Request to Transfer Records

Patient First Name

Patient Last Name

Patient Date Of Birth

I am requesting a copy of the dental records for the above named patient from Dr. Maria Aslani-Breit and I am transferring his/her dental care to another dentist.

I am giving Dr. Maria Aslani-Breit permission to send these records to the following dental office:

Office Name:

Office Location:

Address

City

Zip Code

Office Phone Number:

Office Email:

Reason for Request:

I am aware of his/her dental needs and the risks of not receiving care.

I am the patient's:

Parent First Name

Parent Last Name

Legal Guardian First Name

Legal Guardian Last Name

Patient First Name

Patient Last Name

Parent Signature

Legal Guardian Signature

Patient Signature

Date