Release of Dental Records to Forestwood Dental PATIENT INFORMATION:Name: Full Name Date: MM slash DD slash YYYY AUTHORIZES: Past or Current Dental Office: To transfer information to: Forestwood Dental Dr. Mark Safari & Associates 1390 Major Mackenzie Drive East A1 Richmond Hill, ON L4S0A1 Phone: 905 770 0099 Email: Info@forestwooddentistry.ca INFORMATION TO BE DISCLOSED: All Radiology films/images taken in the past 5 years to be emailed to the above addressLast Hygiene visit Date: MM slash DD slash YYYY Last Complete Oral Exam Date: MM slash DD slash YYYY Last Panoramic x-ray Date: MM slash DD slash YYYY Specific records/information as follows: Attach X-Rays or Files:Max. file size: 64 MB.Once fully read and reviewed, please make sure that the above document is filled out appropriately. By signing below and submitting this document, we are assuming that it has been read in its entirety. All patient signatures will be verified for authenticity in the office.Signature of patient / legal rep:Date: MM slash DD slash YYYY
