location_on 805 Development Dr ❘ Kingston, Ontario K7M 4W6
call(613) 389-8660
mail reception@davidgouettdentistry.com

805 Development Dr, Kingston, ON K7M 4W6

Tel: 613-389-8660 | Email: reception@davidgouettdentistry.com

# TRANSFER OF RECORDS

Dr. David Gouett

Dr. Lin Chen

Dr. Stephanie Reid

DATE

The below name patient (s) has come to our office for continuing dental care. We are requesting any dental health records to be forwarded to our office at reception@davidgouettdentistry.com

Patient Name
Date of Birth
Other Family members to transfer
Previous Dentist
Address
Phone Number
"I hereby give you permission to release and of my dental records to David Gouett Dentistry."
Signature
Date
clinical_notes

### PREVIOUS DENTIST to fill out:

Please forward any of the following information:

1 Date of last recall and cleaning:
2 Date of last Bitewing x-rays:
3 Date of last Panorex x-ray: