890 7Th Avenue West, Owen Sound, ON N4K 5K1 (226)664-2229 (t) (519)286-6608 (f) aspecthygiene@outlook.com

Record Release Form

Dear Doctor or Treating Hygienist, we have a mutual client who is looking to receive dental assessment or therapy within our office. To ensure the client’s assessment can be complete, we are requesting the client’s dental chart to be forwarded to our office.

Client’s Name:

Client’s Date of Birth:

Family members to include:

Dental Office:

Dental Fax or E-mail:

Office to fill in

Please send the following: Date of Last Exams: Recall: Specific: Emergency: New Client/Complete Oral Exam Periodontal Exam: Date of last Radiographs: Bite Wings: Anterior PA’s: Panoramic: Cephalometric: Please e-mail the last set of radiographs along with this form (even if they are over 2+ years old): Any outstanding or currently diagnosed conditions: Please attach and send the last 2 periodontal probing charts- this is required for continuity of care. Any other pertinent information you think we should be made aware of: Please attach any further chart notes/information.

We appreciate you taking the time to send us all the above information.

Date:

Signature: I ____________________________________ hereby release my family’s and my complete dental records as stated above, to be sent as soon as possible to Aspect Hygiene.

Thank you.