Patient form

Records Release Form

Use this form to request dental records and radiographs from a previous office for Dr. Jennifer Shulman and/or Dr. Corey Shulman at Innovation Drive Dental.

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Patient Authorization

Title Patient name Family members included Date of birth

I hereby request and authorize the release of my / my family's dental records and radiographs to Dr. Jennifer Shulman and/or Dr. Corey Shulman of Innovation Drive Dental Office.

Previous Dental Office

Previous dentist or clinic Previous office phone Previous office email Previous office fax Previous office address Please email X-rays to

Information Requested

As per RCDSO guidelines, patients have the right of access to a copy of their dental records. Please honour this request for forwarding copies of original files, most recent full-mouth series, and panoramic film taken within the last 24 months when available.

Date of new patient examination Date of last recall examination Additional notes

Signature

Signer name Date

Draw your electronic signatureOptional for accessibility. If left blank, the typed signer name above is used as the electronic signature.

Online submissions are encrypted and stored in the private Admin inbox. The office receives an email notification without health information.