Name Of Patient* First Last Name of Requesting Parent First Last Date of Request Date Format: MM slash DD slash YYYY Name of New DentistAddress of New Dentist Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number of New DentistEmail of New Dentist Please indicate how you would like the records sent*EmailMailPatient To Pick UpSignature*Date* Date Format: MM slash DD slash YYYY I attest that I have received the above requested records on* Date Format: MM slash DD slash YYYY (today's date)Signature of the parent that is picking up the records*