Date

PATIENT NAME

The above patient(s) would like to thank you for the care you have shown them in the past. In order to provide them with the same continued care, we would appreciate it if you would release their most recent radiographs and records. Where possible please send digital copies of x-rays.

I authorize the release of my/our information to Sydenham Family Dental. Please provide the following information:

Patient Signature:

Date of last complete exam:

Date of last recall exam:

Date of last scaling/hygiene appointment:

Date of last BW:

Date of last PANOREX:

Copies of referral letters from specialists or any other pertinent information.

Thank You

Sydenham Family Dental