Dental Records Release

We send this request to your previous office for you, so your x-rays and history arrive before your first visit.

Previous dental office

Patients

Date of birth
Should we also request records for family members?
Date of birth
Date of birth
Date of birth
Date of birth

Records to send

Which records should be sent?

If unsure, choose the complete dental record.

I ask the dental office named above to send copies of the dental records listed for the patients named on this form to Lunar Smile Dentistry, 475 Wharncliffe Rd S, London, ON N6J 2N1 (info@lunarsmiledentistry.ca). I release the office named above from liability for sharing these records as I have requested.

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Your answers go straight to our office over an encrypted connection. Questions? Call 226-884-2573.