Transfer Records

Records Release Authorization

Authorize your previous dental provider to securely transfer your diagnostic records and x-rays directly to Dental Clinic.

1. Patient Information

Patient Full Name *

2. Previous Dental Practice Details

Previous Dental Office Name *

Previous Office Phone

Previous Office Email / Fax

3. Records to Transfer

Select all records you wish to request:

Full mouth x-rays within the past 5 yearsPanoramic x-rays within the past 5 yearsBitewing x-rays within the past 2 yearsMost current periodontal charting

Additional Instructions or Notes (Optional)

4. Patient Authorization & Signature

I hereby authorize the release and transfer of my dental records, x-rays, and pertinent medical history to Dental Clinic. I understand that this information will be used for my ongoing dental care and records management.

Patient Signature*

Sign here using mouse or finger

Date *

256-bit Encrypted & HIPAA Compliant Transmission