Patient’s Name *
Patient’s Phone Number *
Patient’s Email *
Would you like us to transfer your records from your previous/referring dentist?
NoYes
Referring Dentist’s Name *
Referring Dentist’s Office Name *
Referring Dentist’s Phone Number
Referring Dentist’s Email
I request and consent to the release of my dental records including but not limited to: x-rays, treatment history, diagnosis, or treatment plan.
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