Release of Records

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To provide ABN Family Dental with copies of my/my family’s dental records, radiographs and any other information as outlined below.
MM slash DD slash YYYY


In order for Village Dental to continue providing the above-named patient(s) with the same level of care he/she is accustomed to, please provide the following information:
  • A summary of all information pertinent to the above noted patient(s) continued treatment.
  • Copies or original films from most recent full mouth series, panoramic films and films taken within the last 24 months.
  • Date of last new patient exam (01103)
  • Date of last full mouth series and/or PAN (02102 or 02601)
  • Date of last BW (02142 or 02144)
  • Date of last recall appointment (01202)
Your cooperation with this request is greatly appreciated. Thank you. If you have any questions, please contact us at or (905) 841-3842