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Home
About Us
Team Members
Services
All Services
Children’s & Family Dentistry
Cosmetic Dentistry
Crowns & Bridges
Dental Implants
Dentures
Emergency Dentistry
Invisalign
Orthodontics
Root Canal Therapy
Sedation Dentistry
Teeth Whitening
TMJ Therapy
FAQ
Blog
Contact
New Patients
Request an Appointment Form
Forms
Patient Registration Form
Release of Records Form
905-524-3835
Release of Records Form
Release of Records Form
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*
" indicates required fields
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Date
MM slash DD slash YYYY
I, (name of patient, parent or guardian)
*
Hereby request and authorize (name of previous dentist/dental clinic)
*
To provide Barton Dental with copies of my/my family's dental records, radiographs and any other information as outlined below.
Phone number of previous dentist/dental clinic:
*
Email of previous dentist/dental clinic:
*
Family Members:
Family Member 1
Family Member 2
Family Member 3
Signature of patient, parent or guardian:
Date
MM slash DD slash YYYY
