Authorization for Release of Dental Records

Date:

Dear Dr:

Telephone:

Fax:

Email:

I, , would like to thank you for the dental care you've provided, and ask that in order to preserve the continuity of care, that you forward the clinical records and all current radiographs to the address below.

Please provide the following information to ensure the best optimal care:

Date of last new patient examination (01103): ________________________________________________________

Date of last recare examination (01202): _____________________________________________________________

Date of last panorex (02601): ________________________________________________________________________

Date of last bitewing (02142): _______________________________________________________________________

By checking this box, you provide consent for the disclosure of this information and I request that my records be released.

Thank you for your timely response

Address:
Lawrence West Dental
1141 Lawrence Ave. W.
North York, Ontario
M6A 1E1

Telephone: 416-785-8586
Fax: 416-785-3899

Email Us At:
dentistry@lawrencewestdental.com