Transfer of Records "*" indicates required fields Date* MM slash DD slash YYYY I, (Name of Patient)*Authorize the release of my (and/or my families) dental records and x-rays to be emailed or sent over to Barton Dental from: Previous Dental Office*Family Members:1.*2.3.4.5.Name* First Last Signature*Consent* By submitting this form, I agree to receive marketing messages, including special offers, updates, and news, and understand I can change my preferences at any time. See our Privacy Policy.*CAPTCHA
