Release of Dental Records

RELEASE OF DENTAL RECORDS

REQUEST YOUR RECORDS

First Name

Last Name

Email Address

Phone

DATE OF BIRTH

Previous Dental Office Name

Previous Dental Office Email

Previous Dental Office Phone

Records Requested

Complete dental record X-rays / radiographs Treatment history and clinical notes Other

Other Records (Please Specify)

Authorization

I authorize my previous dental office to release the records requested above to Enamelle Dental for the purpose of continuing my dental care. I authorize Enamelle Dental to request, receive and use these records for my dental care and to communicate with my previous dental office as necessary to facilitate the transfer of my records.

NAME OF PATIENT / PARENT / LEGAL GUARDIAN

Relationship to Patient (if applicable)

DATE

SIGNATURE

Submitting this form authorizes Enamelle Dental to request the records indicated above from your previous dental office.