New Patient Release of Records

Records Release Request

Address

City

State

Zip

Phone Number

Fax Number

Email address

If you have seen a specialist (for extraction, orthodontics, root canal or gum issues or anything else) in the past 3-5 years please list their contact information below. Failure to do so may result in insurance limitations being applied and charges you may be responsible for.

Office Name

Phone#

Work done

I hereby authorize the release of my dental record or copies of such and request that they be transferred

River Forest Dental Studio
344 Lathrop Ave, River Forest, IL, 60305
Phone: (708) 366-6760
Fax: (708) 366-6762
Email: office@riverforestdental.com

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Name of Patient

Date of Birth

X-Rays Requested:

Pano or FMX (w/n 8yrs)

BW (w/in 1.5 yr)

If yes, provide letter on manufacturer & date placed

If yes, tooth #, date seated & material

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Patient/Parent/Guardian Signature

Date

HIPAA requires that we take reasonable steps to protect against email transmission risks but acknowledges that a balance must be struck between the need to secure PHI and the need to ensure that clinicians can efficiently exchange important patient care information. Please be aware that email communication can be intercepted in transmission or misdirected. Please consider communicating any sensitive information by telephone, fax, or mail.

Your information will be encrypted.

New Patient Release of Records

Records Release Request

I hereby authorize the release of my dental record or copies of such and request that they be transferred

River Forest Dental Studio344 Lathrop Ave, River Forest, IL, 60305Phone: (708) 366-6760Fax: (708) 366-6762Email: office@riverforestdental.com

X-Rays Requested:

River Forest Dental Studio

River Forest Dental Studio
344 Lathrop Ave, River Forest, IL, 60305
Phone: (708) 366-6760
Fax: (708) 366-6762
Email: office@riverforestdental.com