Incoming Records Request Form

This form authorizes our office to contact the office of your previous medical provider(s) and have them transfer your patient records to our office.

To: *

Please write the name of the office you would like your records transferred from. If there are 2 or more offices please submit this form again for each office.

Medical/Dental Office Email Address: *

Please type in the email address for the medical or dental office you are requesting your records from.

Your Name: *

Please write your name or the name of the patient you are requesting dental records for if you are their legal guardian.

Birthdate: *

Please write in your birthdate or the birthdate of the patient you are requesting dental records for if you are their legal guardian.

Your Email Address: *

Please enter your email address here. We will email you a copy of this completed signed for upon submission.

By signing and submitting this form, you are requesting all your medical/dental records which include radiographs, periodontal measurements, intra-oral photos, treatment notes, medical history information, and any planned treatment to be submitted to the office of:

Jeffrey S. Tatarin DDS PC

9025 E. Mineral Cir. Ste 101

Centennial, CO 80112

Phone: (303)799-1525

FAX: (303)799-4870

info@tatarindental.com

Signature *

Clear Signature

Please sign your name in the box above.

CALL US: 303-799-1525

9025 E Mineral Cir #101
Centennial, CO 80112