Transfer of Records Form

The following information is required to obtain any relevant dental records from your previous dental office so that we are able to provide you with the best continuity of care.

Transfer of Records

Stirling Dental Centre
9B Tuftsville Rd., Stirling, ON, K0K 3E0, Phone: (613)395-2800 | Fax: (613)395-2808 | Email: info@stirlingdentalcentre.com
Previous Dental Office
Previous Dentist
Previous Dentist's Phone Number*
First Name Of The Patient/Guardian:*
Last Name Of The Patient/Guardian:*
Email Of The Patient/Guardian*
Please list names of additional family members whose x-rays and information are to be released:
To be completed by the previous dental office:
For each patient to be transferred, please include dates of most recent: Initial exam, recall Exam, Scaling/Polish, BW, and PAN. Please forward most recent digital radiographs to: info@stirlingdentalcentre.com
Consent*
- I authorize the release of x-rays and/or relevant patient chart notes to the Stirling Dental Centre.
Authorization of Transfer of Information*
- I authorize the Stirling Dental Centre to transfer the above information as requested and release the Stirling Dental Centre from all legal responsibility or liability that may arise.
Name of Patient/Guardian*
Date*
MM slash DD slash YYYY

Transfer of Records Form

Transfer of Records

Stirling Dental Centre

Previous Dental Office