Transfer of Records Date(Required) MM slash DD slash YYYY I, (Name of Patient)(Required)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(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
