Dental Records Release Form printable pdf download

Dental Records Release Form

Vincent G. Sotero, D.M.D.

1224 Main Street, Suite 1

Branford, CT 06405

203-483-9069

Dental Records Release Form

Patient Name to transfer: ______________________________________________________________

Date of Birth: _____________________

Phone number: _________________________

Other family members to transfer: _______________________________________________________

Previous Dentist or Practice Name: _______________________________________________________

Address: ____________________________________________________________________________

City / St / Zip : ________________________________________________________________________

Phone number: __________________________

Please forward any of the following information that you have: x-rays, probing depth chart, charting,

and photographs to Vincent G. Sotero, D.M.D.

If records are digital, please email to:

Or mail to:

Lockworks Dental Group

Vincent G. Sotero, D.M.D.

1224 Main Street, Suite 1

Branford, CT 06405

I hereby give you permission to release any and all of my dental records to Dr. Sotero.

________________________________________________

__________________

Patient Signature (parent if a minor)

Date

Dental Records Release Form