Auden Park Family Dentistry
You can transfer your patient records (including radiographs/x-rays) from your previous dentist to Auden Park Family Dentistry with this form.
Patient First Name *
Patient Last Name *
Patient’s Phone Number*
Name of Previous Dental Office *
Email of Previous Dentist
Phone of Previous Dentist
Do you wish to transfer additional family members? * NoYes
Additional Patient First Name
Additional Patient Last Name
Date of Last complete exam
Date of last recall exam
Date of last scaling/hygiene appointment
I authorize the release of my/our information to Dr. Yasin Polara
Your Signature
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