Fallston Dental Care

click here for electronic copy

                      Fallston Dental Care                                      

                                                Frederick W. Parker, D.D.S., P.A.                                 

                                               2106 Fallston Road                    Fallston, Md.  21047                                                   

                            410-893-0513 office   443-299-6370 fax    www.fallstondentalcare.com                                    

                        

                                            RELEASE OF RECORDS INFORMATION SHEET                                                          

  I have sent this form or called my previous dentist.             Please request them for me.

 

Patient:                                                                                                                       Birth date:
Address: 
 
Previous dentists name: 
Address:
 
 Phone:

 

 

Periapical or bitewing x-rays that are less than one year old.  Panorex or full mouth series that is less than five years old.

I authorize the release of my dental records to Fallston Dental Care.

 Signature  Print Name  Date

Thank you for your assistance.

Sincerely,

Frederick W. Parker, D.D.S., P.A.