Thomas Quickstad DDS Dentistry for All Ages

Transfer Of Records

I, __________________________, hereby authorize the office of

_____________________________
(name)
_____________________________
(address)

_____________________________
(phone)

to transfer dental records, including x-rays, written chart notes, periodontal charting, referral forms, and any other related forms or paperwork for the following family members:

Name Birthdate
_______________________________
_______________________________
_______________________________
_______________________________
_______________________________

Please send to:
Thomas Quickstad, DDS
3707 Providence Point Drive SE Ste E
Issaquah, Wa 98029
425-391-1331

These records can be in paper form, duplicates or emailed to Dr Quickstad to expedite their arrival.

__________________________________
Printed name of authorized family member

__________________________________
Signature

________________
Date