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)Consent(Required) 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.(Required)CAPTCHA
