Incoming Referrals Outbound Referrals

Outbound Referrals – Bangor, ME

Outbound Referrals

I understand and agree by signing this release form to have my x-rays from Gentle Family Dentistry sent to the office provided above. I also understand that Gentle Family Dentistry can take 48 business hours to release my records.

*Name of Clinic

*Dentist Name

*Address

*Phone Number

*Email

*Signature

*Receiving Doctor

*Full Name

*Date Of Birth

*Relationship To Patient

Other Family Members

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