Dental Records Release Form

Please fill out the form below or download the form if you would prefer to handwrite your responses.

Patient Name to Transfer*
First Last
Date of Birth*
MM slash DD slash YYYY
Phone*
Other Family Members to Transfer
Previous Dentist of Practice Name*
Phone*
Please forward any of the following information that you have: x-rays or photographs to Wake Dental Wellness.

I hereby give you permission to release any and all of my dental records to Wake Dental Wellness.
Signature*
Today's Date: 11/15/2024
If records are digital, please email to: okspit@wakedentalwellness.com

Or mail to: Wake Dental Wellness Si Eun Jeon DDS, PA 127 East Elm Ave. Wake Forest, NC 27587 (919) 556-0444 (919) 554-9010 Fax www.wakedentalwellness.com
Phone
This field is for validation purposes and should be left unchanged.

127 EAST ELM AVENUE, WAKE FOREST, NC 27587