Transfer of Records

  • (To be filled out by previous dentist office)

    Please provide the following information to assist in a smooth patient transition:

    Patient Name:Date of New Patient Exam:
    Date of last Recall Exam:Date of last Panorex:
    Date of last Bitewings:

    Please also forward the most recent x-rays to our office via email.

  • Date Format: MM slash DD slash YYYY