Information Release Form

To: Dr.

Office #:

Office Email:

Molson Park Dental and the above patient(s) would like to thank you for the care you have provided in the past. To ensure continuity of care, please forward all relevant records to our office at your earliest convenience.

Patient Name

I authorize you to provide copies of the most recent radiographs (bitewings / pan / periapicle / FMS).

Also provide the following:

New Patient Examination Date:

Last Recall Examination:

Last Scaling/Polish:

Last X Rays:

Please forward BW's / PA's, and a PAN / FMS. If digital please send to [email protected]

I release you from all legal responsibility of liability that may arise from this authorization.

Date

Information Release Form

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