Records Transfer Form

Patient Name:

Date of Birth:

Previous Dental Office:

Phone #:

I authorize the release of the following information to be sent to Sequim Family Dentistry:

X-rays

Progress notes

Periodontal chart

Other

If Other is selected, please specify:

TO BE COMPLETED BY PREVIOUS OFFICE:

Please send records to smile@sequimfamilydentistry.com OR fax to 360-681-7617 and provide the information below.

Date of last Exam:

Last FMX taken:

Last BWX taken:

Last cleaning date:

Choose One:

ADPRO PM SRP

Your information will be encrypted.