Records transfer

Request for X-rays and Dental Records

Complete this authorization so your previous dentist can transfer recent records to Cedar Crest Dental Care.

Prefer to complete the form by hand?

Download the blank paper form

Print the PDF, fill out every applicable field, sign it, and bring the completed form to Cedar Crest Dental Care when you come in.

Download blank PDF

Please complete this before your appointment.

If no X-rays are received by your appointment, you may be responsible for the cost of current X-rays.

Your answers stay on this deviceThis page does not upload or store your information. It creates the completed PDF locally in your browser.

Previous dental office

Tell us where the request should be directed.

Dentist or practice nameFaxEmail

Patient information

This helps the previous office find the correct chart.

Patient’s full nameDate of birthDate of requestAlso include records forList any additional patient names and dates of birth.

Authorization

Review where the records will be sent.

Please transfer my dental records and X-rays—especially panoramic or full-mouth X-rays taken within the last five years and bitewings taken within the past two years—to:

Cedar Crest Dental Care
1251 S. Cedar Crest Blvd., Suite 207C
Allentown, PA 18103
Digital records: info@ccdc.dentist

I authorize the previous dental office named above to transfer the listed records and X-rays to Cedar Crest Dental Care.

Download and send your completed PDF

After the PDF downloads:

Open your email account and start a new message to the previous dentist using the email address entered above.
Attach the completed PDF from your Downloads folder.
Confirm that the PDF is attached, then send the message.