Transfer of Records

Patient Name

Clinic

Name

DOB

Name

DOB

Name

Name

COE & FMS

COE & FMS

RC

RC

BW(s)

BW(s)

PAN

PAN

PA(s)

PA(s)

Sc & Pol

Sc & Pol

Signature

Date

Patient’s phone number

I, , hereby request the release/transfer of my dental records and radiographs from to be forwarded to Centre Street Dental.

Names of records being requested:

Name

DOB

Name

DOB

Name

Name

COE & FMS

COE & FMS

RC

RC

BW(s)

BW(s)

PAN

PAN

PA(s)

PA(s)

Sc & Pol

Sc & Pol

Signature

Date

Patient’s phone number

At our dental office in Espanola, we warmly welcome families of all ages, providing comprehensive care tailored to each individual’s needs.

Espanola Dentist Hours

Monday to Thursday: 9:00 AM – 5:00 PM

Friday: Appointments Only

Contact US

© 2026 All rights reserved

Powered by clickguru