Transfer of Records

Previous Dental Office:

Address Line 1

Address Line 2

City

State

Zip Code

Country

Previous Dentist Name:*

Dentist's Phone/Mobile

First Name

Last Name

ID Number

Spouse / Guardian Name

Consent

I authorize to release x-rays and/or details of my/our treatment to ToothVue Dental.

(To be filled out by previous dentist office)
Please provide the following information to assist in a smooth patient transition:

Patient Name:	Date of New Patient Exam:
Date of last Recall Exam:	Date of last Panorex:
Date of last Bitewings:
Date of last hygiene appointment:

Please also forward the most recent x-rays (including the last panoramic) to our office via email.