REQUEST TO TRANSFER DENTAL RECORDS AND X-RAYS

If you would like your dental records forwarded to our office, please complete this form and send it to your previous dental office. Thank you!

Patient's Name:

Date of Birth:

Home Address:

Records and x-rays may be emailed to frontdesk@hatfieldfamilydentistry.com

Previous Dentist:

Name:

Address:

Phone:

Email:

Fax:

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

Signature of Patient or Guardian:

Date:

Your information will be encrypted.