Transfer of Records Name Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First TelephoneName of the Patient/Guardian:* Name of the Previous Provider's Name:* I authorize to release x-rays and/or details of my/our treatment to Aylmer Family Dental. (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. Please list names of additional family members whose x-rays and information are to be released: I authorize you to transfer the above information as requested and release you from all legal responsibility or liability that may arise. Name of patient/guardian: Date MM slash DD slash YYYY Signature of patient/guardian:PhoneThis field is for validation purposes and should be left unchanged.
