Forest Falls Dental - Patient Records Release Form

Patient Records Release Form

Forest Falls Dental
Date *

Month Day Year
Date
Patient Name *

First Name Last Name
Patient Date of Birth: *

Month Day Year
Date
Email
example@example.com
I would like my dental records sent to: *

Forest Falls Another Dental Office
Please fill in the blanks below

Previous Dental Office:Name of Practice Here* may Release Records to:

Name of Practice: Forest Falls Dental
Mailing Address: 10 Forest Falls Drive, Unit 9, Yarmouth, ME. 04096

Email Address: yarmouth@beautifulsmile.com
Phone: (207) 846-3966
Fax: (207) 204-3428
Please fill in the blanks below

Forest Falls Dental may Release Records to:

Name of New Dental Office:Name of Practice Here*
Mailing Address:
Email Address:ex: info@newdentaloffice.com*
Phone:207-555-1212
Fax:207-555-1212
The records that will be included, but are not limited to: personal patient information, medical and dental histories, examination records, and radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and other related materials.

I expressly release from liability the above names person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.
Are you the patient or a parent/guardian? *

Patient Parent or Guardian
Please Type Your Name *

First Name Last Name
Patient Signature: (use mouse or finger to draw your signature) *

Clear
Please type the name of the Patient's Parent or Guardian signing the release *

First Name Last Name
Parent / Guardian Signature: (use mouse or finger to draw your signature) *

Clear
Today's Date *

Month Day Year
Date
Should be Empty: