Records Release Request

Apple Dental Centre - 73 Wilson St W, Unit 20, Ancaster, ON, L9G 1N1

Records Release Request

Patient First Name

Patient Last Name

Previous Dental Office Name

Phone number

Street Address

Address Line 2

City

Province

Postal Code

I authorize the release of my dental records, including x-rays and request that they are transferred to the dental office below' ln addition to myself, please include the following members of my family:

First Name

Last Name

First Name

Last Name

First Name

Last Name

First Name

Last Name

Name and Signature of Parent or Legal Guardian below:

First & Last Name

Valid First & Last Name is required.

Email Address

Valid email is required.

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