location_on805 Development Dr ❘ Kingston, Ontario K7M 4W6

call(613) 389-8660

mailreception@davidgouettdentistry.com

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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

Patient Signature

Open the popup and sign inside the pad.

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: