Record Release Request Form in Hamilton, BM

Name Of Patient*
First Last
Name of Requesting Parent
First Last
Date of Request
Name of New Dentist
Address of New Dentist
Street Address Address Line 2 City State ZIP Code
Phone Number of New Dentist
Email of New Dentist
Please indicate how you would like the records sent*
- Email
- Mail
- Patient To Pick Up
Signature*
Your Name
Your Name
Your Name
Date*
I attest that I have received the above requested records on*

(today's date)
Signature of the parent that is picking up the records*
Your Name
Your Name
Your Name

Par-La-Ville Dental