REQUESTING RECORDS FORM
THE OFFICE OF
ADDRESS
PHONE
EMAIL
Date:
I
request my most recent dental records and radiograph be emailed in .jpg format to:
info@smileperfectionaz.com
Signature
Patient's DOB
Date of Last Visit:
Last Recare:
Date of Last:
BW'S
FMX
PANO
Patient's Address
City, State, Zip
Telephone