 |
|
|
|
|
| Date:________________ | |
Name and Address of requesting dental office: |
_____________________________________________ _____________________________________________ _____________________________________________ |
Patient Name:______________________ |
Date of Birth:______________ |
| Transferring
Radiographs/Records
|
|
| This office has been requested to transfer to you the radiograph and/or records of the above named patient. | |
_________Radiographs are enclosed |
Comments:_____________________________ ______________________________________ |
_________Radiographs are NOT enclosed |
Comments:_____________________________ ______________________________________ |
| Requesting
Radiographs/Records
|
|
| ___________This office is requesting radiographs and/or records for the above named patient. | |
|
I herby authorize and request the release of my radiographs/records to: Alliance for Dental Care |
|
|
Patient Signature:___________________________ Date:________________ |
|