Outgoing Records Request Form

Outgoing Records Request Form

Use this form to initiate a request to transfer your medical records to another provider, individual, or entity.

1Patient Information
2Future Provider Information
Your Name(Required)
Please enter the name and date of birth for each patient wishing to transfer their medical records. If you wish to submit your information to more than one office, please submit this form for each office.
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.
Medical Records Request(Required)
Signature(Required)
Please sign your name in the field below.