Transfer of Records

Transfer Of Records

Previous Dental Office:

Phone Number:(Required)

Email:(Required)

Previous Dentist Name:(Required)

Prefix Last Name

Name Of The Patient/Guardian:(Required)

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:(Required)

Date(Required)

Signature Of Patient/Guardian:(Required)