Form

REQUEST TO RELEASE/TRANSFER DENTAL RECORDS

By signing this form, I hereby request the release and/or transfer of my dental records and radiographs.

First Name

Last Name

Date Of Birth

William I. Kincaid, III, DDS
James T. Purvis, DDS
Donovan Godwin, DDS

Justin Shimer, DMD

1007 Newman Road

New Bern NC, 28562
Phone (252)636-0011 Fax (252)288-5715

Email to: scheduling@kincaidandpurvis.com

Dental Office Information

Address

City

Zip Code

Phone

Fax Number

Patient/Legal Guardian Signature

Date

Please list any additional patients covered by this release:

Patient's Name

Date Of Birth

Patient's Name

Date Of Birth

Patient's Name

Date Of Birth