PATIENT NAME

NAME OF PREVIOUS DENTAL OFFICE

The above patient(s) have requested that the following information and any radiographs two years old or less be forwarded to our office for continued care.

Date of last recare exam

Date of last scaling/prophy:

Date of last radiographs – bitewings/periapicals:

Date of last panorex radiograph:

I understand that this document will be sufficient to serve as a legal release as required by the RCDS since November 1995. I hereby authorize Sydenham Family Dental to obtain the above information

From Doctor

Signature

Date

Notes