Become A Patient

Dr. Kadri Dental Office
5841 Malden Rd Unit 174,
LaSalle, ON
N9H 1S3
Telephone: (519) 962-9222

Request for Dental/Medical Information

Name *

Telephone Number *

Email Address *

Address (copy) *

Name of Previous Dental Clinic & Dentist Name *

The above named patient(s) have recently become patient(s) at our office. I understand that you may have records/radiographs, would you kindly forward the patient's Odontogram, note history, specialist's reports, pre-determinations for any treatment in progress and copies of the treatment records from the last five years. If records are digital, please email them to info@kadridental.ca, if not please mail or fax.

Date of NP Exam

Date of Last Recall *Office Use Only*

Pan

BW's

I hereby release my Dental/Medical records and radiographs

Patient's/Guardian's Signature *

Date *