REQUEST TO TRANSFER RECORDS TO NEW PROVIDER This field is hidden when viewing the formToday's DatePatient Name*New Doctor's Name or Office Name*Where would you like us to send your records? Records Release Statement*When a patient moves, or, for other reasons, there is a necessity to change orthodontists during the course of ongoing orthodontic treatment, it is highly advantageous for all involved parties that the transfer be as prompt and convenient as possible. Of paramount importance is the identification of an orthodontist who will accept the patient and successfully complete the treatment. I understand the risks involved with un-monitored active treatment including but not limited to shifting of teeth, impairment of treatment results, relapse, and decline in my dental and orthodontic health. The American Association of Orthodontists represents over ninety percent of the orthodontic specialists in the U.S. and Canada. Your current doctor is a member and will assist you in finding a qualified orthodontist. It is necessary that your records be transferred to assure that the receiving orthodontist is knowledgeable of your orthodontic condition(s), orthodontic treatment goals, the current treatment plan, and related financial arrangements. By requesting transfer of my care, I now and forever release and discharge ZL Dentistry & Orthodontics doctors, his/her agents, employees, professional corporation, insurers and assigns from any loss, costs, damages or expenses arising from orthodontic treatment. I understand that this is a full waiver and release of any and all claims I or anyone claiming through or on behalf of the named patient may now have or may acquire in the future. I authorize ZL Dentistry & Orthodontics to release all records for the purpose of treatment continuity to my new provider listed.Signature*Relationship to Patient (if minor)signed @ ip address: 37.111.214.245This field is hidden when viewing the formsigned at ip address Δ
