Records Release

Thank you for choosing Chapman Mills Dental for the care of your patients.

Please complete the form below to submit your patient's medical records to our office.

Today's Date *

Patient Name *

We at Chapman Mills Dental and the above patient(s) would like to thank you for the care you have shown them in the past. In order to provide them with the same continuing care, we would appreciate it if you would please forward their most recent radiographs and records that you may have on file. All information received will be held in the strictest confidence. Diagnostically acceptable duplicate films and photocopies of written records would be appreciated.

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Upload Records

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Upload Records

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Kindly provide the following information:

Initial Examination *

Last Recall Examination: *

Last Scaling/Polishing/Fluoride: *

Any Other Pertinent Information: *

Patient/Guardian: *

I hereby authorize the release of the dental records as requested herein. *

Yes

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Records Release Form

Please complete the form below to submit your patient's medical records to our office.

New Patients Always Welcome