Patient Release of Dental Records

PATIENT RELEASE OF DENTAL RECORDS

I authorize my records to be released and all images/ x-rays or pertinent records be emailed/sent securely to Robert Derr and Amy Chi Family Dentistry. Please email them to info@DentistEP.com

Previous Dental Office name

Previous office email address

Previous-dental-office-phone

Date of x-rays:

Type of images

Date of panoramic FMX (full mouth)

Date of Bitewing Images:

Signature:



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