Request For Transfer Of Dental Records

I hereby authorize Kids Dental Experts to provide:

(Party to whom the records will be sent)

Address

Address Line 1

City

State

Zip Code

Phone

Email

Patient: Relationship for

with copies of records for:

Name of Patient:

Date of Birth:

Name of Patient:

Date of Birth:

Name of Patient:

Date of Birth:

I understand that the specific type of information to be disclosed may include a detailed report of examinations, treatment, prognosis, and copies of current x-rays. This consent is effective until Kids Dental Experts® receives notice that no additional information may be released. I understand that after records have been released to another provider, Kids Dental Experts® cannot be held accountable for their use.

Reason for transfer:

I’m being referred.
I’m seeking a second opinion.
I have an insurance plan that mandates service be performed by another provider.
I have a new dental care provider

Any comments:

Signature

Clear Signature

(The signature of a parent or guardian is required if patient is under 18 years of age)

Relationship to patient:

Date: