PPFDdesk Dental Records Release Form (FAMILY)

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Incoming Dental Records Release

Name of Patient #1 & DOB *

Name of Patient #2 & DOB *

Name of Patient #3 & DOB

Name of Patient #4 & DOB

Name of Patient #5 & DOB

Name of Patient #6 & DOB

Name of Patient #7 & DOB

Name of Patient #8 & DOB

Phone Number (Head of Household) *

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 as the Head of the Household, 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 all incoming dental records from my family.
*

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 as Head of Household.
*

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