Transfer of Records

Previous Dental Office:
Phone Number:*
Previous Dentist Name:*
Prefix Last Name
Name Of The Patient/Guardian:*
First Last
*
- I authorize to release x-rays and/or details of my/our treatment to Henley Dental.

(To be filled out by previous dentist office)
Please provide the following information to assist in a smooth patient transition:

Patient Name:	Date of New Patient Exam:
Date of last Recall Exam:	Date of last Panorex:
Date of last Bitewings:
Date of last hygiene appointment:

Please also forward the most recent x-rays (including the last panoramic) to our office via email.

Please list names of additional family members whose x-rays and information are to be released:
- I authorize you to transfer the above information as requested and release you from all legal responsibility or liability that may arise.
Name of patient/guardian:*
Date*
Year
Month
Day
Signature Of Patient/Guardian:*
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