Transfer of Records Date(Required) MM slash DD slash YYYY I, (Your Name), authorize the release of my (and/or my families) dental records and x-rays to be emailed or sent over to Tomken Dental from (Previous Dental Office).Your Name(Required) Previous Dental Office(Required) Family Members:1.(Required) 2. 3. 4. 5. Name(Required) First Last Signature(Required)CAPTCHA
