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Patient
| Name: | _________________________________ | Patient ID: | _________________________________ |
| Phone: | _________________________________ | Email: | _________________________________ |
| Address: | _________________________________ |
Transfer From
| Original Dentist: | _________________________________ | Clinic: | _________________________________ |
| Fax: | _________________________________ | Email: | _________________________________ |
| Phone 1: | _________________________________ | Phone 2: | _________________________________ |
| Address: | _________________________________ |
Transfer To
| New Recipient: | _________________________________ | Clinic: | _________________________________ |
| Fax: | _________________________________ | Email: | _________________________________ |
| Phone 1: | _________________________________ | Phone 2: | _________________________________ |
| Address: | _________________________________ |
Authorized Information to Disclose
Method of Transfer
Reasons for Disclosure
I, the patient, understand that I may revoke my consent, in writing, at any time. I understand that my information will be held in the strictest confidence and will be read, shared, and held by no parties other than those who transfer the information and those who receive it.
(Patient's Signature)
(Dentist's Signature)
(Date)
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