S M I L E D E S I G N!
E L L S W O R T
H!
A A R O N
P A L M E R, D M D!
Dental Records Release Form
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____________________DOB:____________
Patient Name to Transfer:
Practice Name: _________________________________
Address: ______________________________________
City/ State/ Zip: ________________________________
Phone Number: ________________fax: ________________
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Transfer to:
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Smile Design Ellsworth
Aaron Palmer D.M.D
382 State Street
PO Box 611
Ellsworth ME 04605!
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I request the above name doctor to release the information specified below:
__ X- Rays,
__Probing Depth Chart,
__Charting
__ photographs
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Digital copies can be emailed to
I hereby authorize release any and all of my dental records to Dr. Palmer.
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____________________________
_________________
Patient Signature (Parent if a Minor)
Date