Release of Records

"*" indicates required fields

I, (name of patient, parent or guardian)*

Hereby request and authorize (name of previous dentist/dental clinic)*

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

Phone number of previous dentist/dental clinic:*

Email of previous dentist/dental clinic:*

Signature of patient, parent or guardian:

Date

To Be Completed by Previous Dentist/Dental Clinic

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 info@abnfamilydental.ca or (905) 841-3842