Patient Release Information

Date

Office Name

Phone No.

Please release all files(including the patients chart) and radiographs for the following patients(s):

Could you also provide us with the following information:

4.Any outstanding treatment needed:

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Name / Signature

Date

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Patient Release Information

Could you also provide us with the following information:

1. Dates of all recent x-rays:

2. Dates of initial new patient exam:

3. Dates of last recall exam, polish, scaling:

4.Any outstanding treatment needed:

Tanglewood Dental Office