Pediatric Dentist Dearborn,  MI

Patient Transfer Form

AUTHORIZATION FOR TRANSFER OF DENTAL RECORDS

to remit my dental records to the dentist indicated below.

right to review my records when necessary for the time I was under his/her care.

is no longer responsible for my future dental care or needs after 30 days from the date below.

YOUR NAME AND ADDRESS

DENTIST NAME/ADDRESS

SIGNATURE

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