Release of Dental Records | Dalseth Family & Cosmetic Dentistry

Need to transfer your dental records?

We're here to make the process simple. Whether you're requesting records from another dental office to be sent to Dalseth Family & Cosmetic Dentistry or asking us to send your records to another provider, you'll find everything you need on this page.

Choose the option that fits your situation below. You can either complete the form online or download a printable version to fill out and submit at your convenience.

Request Records to Dalseth

Request Records From Dalseth

Download Authorization Form (PDF)

Moving Your Dental Care to Dalseth?

If you're becoming a patient at Dalseth Family & Cosmetic Dentistry, this form authorizes your previous dental office to send your dental records to us. Having your records in advance helps our team better understand your dental history and provide seamless, personalized care from your very first visit.

Request Records Sent to Dalseth Family & Cosmetic Dentistry

Date

Patient Information

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Email(Required)

Dental Clinic

Address

Street Address City State ZIP Code

Phone

Authorization

I authorize the release of my dental and medical information to Dalseth Family and Cosmetic Dentistry (bitewings within 18 months, panoramic and/or full mouth series within 5 years).

Signature

Need Your Dental Records Sent to Another Provider?

If you're requesting that Dalseth Family & Cosmetic Dentistry send your dental records to another dental office or healthcare provider, please complete this authorization form. We'll process your request as quickly as possible to help ensure a smooth transition of your care.

Request Records Sent from Dalseth Family & Cosmetic Dentistry

Date

Patient Information

Name(Required)

First Last

Address(Required)

Street Address City State ZIP Code

Email(Required)

Dental Clinic

Office/Doctor’s Name

Address

Street Address City State ZIP Code

Phone

Authorization

I authorize Dalseth Family and Cosmetic Dentistry to release my dental and medical information (bitewings within 18 months, panoramic and/or full mouth series within 5 years) to:

Signature

Questions?

If you're unsure which form you need or have questions about transferring your dental records, our friendly team is happy to help. Give us a call, and we'll guide you through the process.