About this template
A dental records release form is essential for dental practices needing to request, transfer, or receive patient medical and dental history from previous healthcare providers. Ensuring a smooth transition of care requires precise patient authorization, detailed provider information, and clear identification of the records being requested.
Doc2Form allows dental clinics to instantly convert documents like records release authorizations into fully functional Google Forms. Staff can easily collect patient details, specify disclosing and receiving providers, outline exact treatment dates or records needed, and secure proper consent before initiating a transfer. Transitioning this paperwork to Google Forms streamlines administrative workflows, minimizes paperwork bottlenecks, and keeps patient onboarding organized.
Whether you are opening a new patient file or coordinating specialized care with an orthodontist or oral surgeon, this digital release form makes data collection fast, accurate, and accessible from any device.
Key features
- Collect complete patient identification and contact details.
- Specify both disclosing and receiving healthcare providers.
- Indicate exact types of dental records and treatment history requested.
- Include expiration dates and formal patient consent language.
- Access submissions instantly via Google Sheets for easy tracking.
Use cases
Transferring patient history when a new patient joins your dental pra…
Transferring patient history when a new patient joins your dental practice.
Sending records to a specialist, orthodontist, or oral surgeon.
Fulfilling formal patient requests to share their records with anothe…
Fulfilling formal patient requests to share their records with another provider.
What this form collects
- Patient Full Name (Short answer)Enter your first, middle, and last name.
- Date of Birth (Date)Please enter your date of birth in MM/DD/YYYY format.
- Phone Number (Short answer)Enter the best phone number to reach you if we have questions about your request.
- Email Address (Short answer)We will use this email to send confirmation of your records request.
- Residential Address (Paragraph)Include your street address, city, state, and ZIP code.
- Disclosing Provider Name (Short answer)Name of the doctor, dentist, or facility holding your current records.
- Disclosing Provider Contact Information (Paragraph)Provide the phone number, fax, or address of the previous provider if known.
- Receiving Provider Name (Short answer)Name of the dental clinic or doctor who should receive these records.
- Related Dental Records Requested (Checkboxes)Select all types of records you would like transferred.
- Authorization Expiration Date (Date)Select the date when this release authorization expires (or select a date one year from today).
- Patient Acknowledgment and Signature (Short answer)By typing your full legal name below, you confirm that you authorize the release and transfer of your dental records as specified above.
FAQ
What is a dental records release form?
It is a legal authorization document signed by a patient allowing a dental practice to request, obtain, or share their medical and dental records with another healthcare provider.
Why do dental offices need a records release form?
It ensures compliance with patient privacy expectations and grants your clinic the formal permission required to contact previous providers and request past x-rays, charts, and treatment notes.
Can I customize the fields in this Google Form template?
Yes! Because it lives in your Google Drive, you can easily add, remove, or edit questions to match your practice's specific intake workflow.
How does Doc2Form help me set this up?
Doc2Form instantly transforms static documents or templates into ready-to-use Google Forms, saving you hours of manual form building.
Where are the submitted patient authorizations stored?
All responses are securely collected and organized in a linked Google Sheet associated with your Google Form.
Get this form in your Google Drive
Save a copy to your Google Drive with one click (uses 1 credit). Or build from a PDF or description in the app.