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.

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 write in the office’s email address or FAX number
Please write your name or the name of the patient you are requesting dental records for if you are their legal guardian.
Please write in your birthdate or the birthdate of the patient you are requesting dental records for if you are their legal guardian.

By signing and submitting this form, you are requesting all your 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