Records Request Form | New Dentist - SF Pediatric Dentistry

To request to have your child(ren)'s records sent to a new dental provider and have their chart inactivated in our system, please fill out the following form.

* Indicates required field

Child's Name *

First

Last

Child's Name *

First

Last

Child's Name *

First

Last

Parent / Guardian *

First

Last

Parent / Guardian *

First

Last

I hereby request (check all that apply): *

A summary of treatment / transfer report X-rays

be sent to:

New dentist's name or office name: *

New dentist's city & state: *

Please confirm your email address that we have on file: (not the new dentist's email address) *

If your email address is different to the one we have on file for you, we will give you a call to confirm.

Email Disclaimer: *

I recognize that email is not a secure form of communication, and that there is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to, or intercepted by unauthorized third parties.

Submit

Records Request
New Dentist

Location & Contact

Hours

Records Request​New Dentist

Location & Contact

Hours

Records Request
New Dentist