Records Release Request

Please fill out all of your insurance information below:

I am transferring due to(Required)

Moving to another state/area

Recently moved nearby

I would like a second opinion

Unsatisfied with current practice

Other

I am transferring

To Lakebrink Dental

To another dental office

Name of patient transferring(Required)

First Name Last Name

DOB(Required)

Additional family members transferring & DOB

Patient Email(Required)

Patient Phone(Required)

Name of practice you are transferring from(Required)

Name of practice you are transferring to(Required)

Email of the practice you are transferring to(Required)

Phone # of the practice you are transferring to(Required)