Request to Copy and Transfer Dental Records Form

Dr. Sein H. Siao and Associates

Patient Name

Date

Family Member including

I request my (or my families) dental records and/or x-rays be transferrred to

Name

Address

I give the office of Sein H. Siao, D.M.D. and Associates permission to release this information

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.

Patient Signature

Date

Your information will be encrypted.