SmilesInc | Dental Records Release

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Authorization For Release Of Dental Records

Patients Name*

Date Of Birth*

Address*

Phone*

Email*

Current Dental Office: Smilesinc 12, Dundonald Street Hamilton Bermuda HM 09 Phone: 441 296 0990 Email: smiles@smilesinc.bm

New or Referred to Dental/Medical Office*

Address*

Phone:*

Email*

I, the undersigned hereby authorize the transfer of my patient dental records to the office listed above. The following information has been sent via (Please select which one)*

Email

hardcopy

Progress notes*

Yes

No

X-rays*

Yes

No

Lab reports*

Yes

No

Other

I understand that this transfer of information is essential for ensuring the continuity of dental care/treatment.*

Date:

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Download PDF of Dental Records Release Authorization To Print and Fill Out

Download PDF of Dental Records Release Authorization To Print and Fill Out

SmilesInc

12 Dundonald Street

Hamilton, HM 09

Get in touch

 441 296 0990

 smiles@smilesinc.bm

Office Hours

Sunday Closed

Monday - Friday 08:00 - 06:00

Saturday 08:00 - 01:00

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