X-Ray & Records Transfer — Eastgate Family Dental

Eastgate Family Dental

Grand Rapids, Michigan

2003 Burton St SE · Grand Rapids, MI 49506
Phone: (616) 245-9830 · Fax: (616) 245-5026
www.eastgatefamilydental.com

Authorization for Release of Dental Records & X-Rays

Patient Information

Patient Last Name

Patient First Name

Date of Birth

Current Address

City

State

Zip

Phone Number

Previous Dentist / Practice Name (records being requested FROM)

Previous Dentist Address

City

State

Previous Dentist Phone

Previous Dentist Fax

Previous Dentist Email (if known)

Please Release Records To:

Practice Name

Address

City

State

Zip

Phone

Fax

Attention / Doctor

Records Requested

Please check all that apply:

Specific dates or additional details (optional)

Patient Authorization

I hereby authorize the release of any dental records, x-rays, and other information concerning my dental care to Eastgate Family Dental as indicated above. I understand that this information will be used for the purpose of continuing my dental care. I understand that I may revoke this authorization in writing at any time. This authorization will expire one year from the date of my signature unless I specify an earlier date.

Signature of Patient, Parent, or Guardian

Date

Print Name of Patient, Parent, or Guardian

Relationship to Patient

A copy of this authorization is as valid as the original. Records requested may be subject to a reasonable duplication fee charged by the releasing practice.

For Office Use Only

Date Request Sent

Sent Via

Date Records Received

Received By