Patient Records Transfer Form

Please correct the errors described below.

which is in the possession of this person or entity, to

We appreciate a reason given for the transfer:

These records include, but are not limited to: personal patient information, medical and dental histories, examination records, radiographs, treatment plans, treatment records, referral and consultation recommendations and reports, and other related materials.

I expressly release from liability the above named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.

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.

Your information will be encrypted.