PPFDdesk Dental Records Release Form (INDIVIDUAL)

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Incoming Dental Records Release

Patient Name *

Date of Birth *

Phone Number *

Previous Dentist or Practice Name *

Previous Practice Phone # *

Previous Practice FAX # *

Previous Practice Email *

I hereby give permission to release any and all of my dental records to Paw Paw Family Dentistry. *

Yes

By typing in my name below, I confirm that I've answered the above questions to the best of my ability and give my approval to Paw Paw Family Dentistry to receive my incoming dental records. *

NOTE TO PATIENT: Please have your previous dentist forward any current x-rays BEFORE your appointment. This is to help save you money, because if we do not have your current x-rays on the day of your visit, we may need to take new ones, and that entire fee will be your responsibility. Insurance companies will NOT PAY for x-rays twice if what they have on file is considered current. By typing your name below, this signifies that you understand and accept this information. *

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