Transfer of Records - Henley Dental

Transfer of Records

Transfer Of Records

  • (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.

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