Dentistry On 66

Patient Record Release Form

I would like to transfer my xrays taken at your office to Dentistry of 66. In order to maintain continuity of care we ask that past xrays and treatment records (and any other information pertinent to their care) be forwarded to our office as soon as possible. All information will be held in the strictest of confidence.

Please include the dates and any dental related concerns.
Thank you.

d066 Patient release form
I, ____________ hereby authorize to release my dental records to Dentistry on 66.
I, ____________ hereby authorize to release my dental records to Dentistry on 66.
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