Records Transfer Form 

 

I am requesting a transfer of the Dental Records for:

 

______________________________________________________ 

 

Please forward the following: 

 

1.  Any radiographs that are 2 years old or less.

2.  A copy of the most current Health History.

3.  A copy of all records for the previous 5 years.

4.  Any other pertinent information such as letters from physicians, hospitals, etc.

that might pertain to past and future dental treatment. 

 

Please forward the records to:

 

Marshall T. Snodgrass, D.D.S., P.C.

14303 West State Hwy 38

Marshfield, MO 65706 

 

Signature (patient or guardian):  ___________________________________  

 

Date: ________________________________________________