Patient Release Form

YOUR BEST DENTAL EXPERIENCE

Patient Information

Date Of Birth

Patient Name(s):

The above patient(s) would like to thank you for the care you have shown them in the past. In order to provide them with the same continued care, we would appreciate it if you would release their most recent radiographs and records. Where possible please send digital copies of x-rays.

I authorize the release of my/our information to Sydenham Family Dental. Please provide the following information:

Signature

TO BE FILLED OUT BY DENTAL OFFICE

Date of last complete exam:

Date of last recall exam:

Date of last scaling/hygiene appointment:

Date of last BW:

Date of last PANOREX:

Copies of referral letters from specialists or any other pertinent information.

Thank You,

Sy den h am Fam i l y D en tal

4310 Stagecoach Road, Sydenham ON K0H 2T0
T: 613-376-6652 F: 613-376-6071
Email: [email protected]

YOUR BEST DENTAL EXPERIENCE