Patient Transfer Form

I authorize the dentist named below to remit my dental records to the dentist indicated below.

By authorizing this transfer, I understand I am not revoking the releasing dentist’s right to review my records when necessary for the time I was under his/her care.

I understand that the releasing dentist is no longer responsible for my future dental care or needs after 30 days from the date below.

Please enter the following information below.