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.

Incoming Records Request Form

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.
Please type in the email address for the medical or dental office you are requesting your records from
Your Name(Required)
Please write your name or the name of the patient you are requesting dental records for if you are their legal guardian.
Birthdate(Required)
Please write in your birthdate or the birthdate of the patient you are requesting dental records for if you are their legal guardian.
Please enter your email address here. We will email you a copy of this completed signed for upon submission.
Medical Records Request(Required)
Signature(Required)
Please sign your name in the field below.