Date

Re

DOB

To Doctor

The above patient has 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 Dr. Robert Clinton and Dr. Yasin Polara to obtain the above information

From Doctor

Signature

Date

Notes