I AM TRANSFERRING DUE TO

MOVING TO ANOTHER STATE/AREA

RECENTLY MOVED NEARBY

I WOULD LIKE A SECOND OPINION

UNSATISFIED WITH CURRENT PRACTICE

OTHER

I AM TRANSFERRING

TO LAKEBRINK DENTAL

TO ANOTHER DENTAL OFFICE

NAME OF PATIENT TRANSFERRING

First Name

Last Name

DOB

ADDITIONAL FAMILY MEMBERS TRANSFERRING AND DOB

PATIENT EMAIL

PATIENT PHONE

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NAME OF PRACTICE YOU ARE TRANSFERRING FROM

NAME OF PRACTICE YOUR TRANSFERRING TO

EMAIL OF THE PRACTICE YOU ARE TRANSFERRING TO

PHONE # OF THE PRACTICE YOU ARE TRANSFERRING TO

(###)

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DATE

YYYY

BY INITIALLING THIS FORM, I HEREBY GIVE MY PERMISSION TO RELEASE ANY AND ALL OF MY DENTAL RECORDS TO LAKEBRINK-MITTS DENTAL TO THE PRACTICE MENTIONED ABOVE OR FOR LAKEBRINK-MITTS DENTAL TO REQUEST RECORDS ON MY BEHALF.