Transfer Records

Records Release Authorization

Authorization to Release Dental Records

Authorization for your previous dental provider to release your dental records to Dr. Mark J. Andrews.

Patient Full Legal Name *

Previous Dental Practice Details

Previous Dentist / Office Name *

Previous Office Phone Number

Previous Office Email / Fax (If known)

Request Dental Records to Include: *

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

Deliver Records To:

Dr. Mark J. Andrews, DDS Family and Cosmetic Dentistry
7311 NE 141st Street, Suite 1, Kirkland, WA 98034
Email: welcome@ddskirkland.com | Phone: 425-821-8100 | Fax: 425-821-5704

Signature Date(Auto-set to today)

Patient Signature*

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