Patient Records Transfer Form

I, hereby request and authorize Rodney G. Sigua, D.D.S. to disclose and provide copies of any and all clinical treatment records and information concerning my care,

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

Name of new dentist, specialist, consultant, attorney or insurer

Address

Telephone

We appreciate a reason given for the transfer:

I am happy with past service but I am moving from the area.

My personal hours conflicts with the office hours.

Please explain

I have a personality conflict with the Staff/Doctor.

Please explain

The cost of treatment does not meet my financial needs.

Please explain

I disagree with the treatment that has been recommended.

Please explain

I am unhappy with the services provided.

Please explain

The office environment is not suited to me.

Please explain

I want a second opinion to be reassured of my treatment choice.

Other comments are appreciated:

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.

Signature

Date

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