Pediatric Dentist Princeton NJ 08540 - Record Release Form | The Little Teeth Workshop

Patient Information

Patient's First Name *

Patient's Last Name *

Parent/Guardian Name *

Patient's DOB *

Email *

Previous Dentist Information

Please provide information about your child's previous dental provider so we can request their records.

Previous Dentist/Practice Name *

Previous Dentist Address *

City *

State *

Zip *

Previous Dentist Phone *

I hereby authorize the release of dental records, including X-rays, treatment history, and any other relevant dental information for the patient named above from the previous dental provider to The Little Teeth Workshop. This authorization is valid for one year from the date of signature.

Signature

Parent/Guardian Signature (Type Full Name) *