Campbell Ortho

Request for Release of Records

Please fill out this form you will still need to come into the office and sign the form. Optionally you can print this form and Mail it to our office.

9317 Leesville Road - Suite 105 - Raleigh, NC 27613
Phone (919) 870-8298 - Email: info@ericcampbellortho.com

Standard Release

I,

, hereby request and give my permission to Eric S. Campbell, DDS, MDS, PA to provide Dr.
any and all information he/she may request with respect to the orthodontic care of
.

Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, orthodontic x-rays, intraoral and/or extraoral photos, and models, and copies of any pertinent dental records and medical records on file with said provider.

Patient Information

New Doctor Information

Please Read and Sign Below

The information that I have provided is correct to the best of my knowledge. Please print, complete and sign the above form and fax back to us as soon as possible, so we can forward the records to your new orthodontist. Please be prepared to pay either $50 or $100 to process the transfer, depending on whether the lab work of model duplication was incurred or not.

Finances are settled in accordance with the American Association of Orthodontists' proration formula for early discontinuation of treatment. 25% of total fee is incurred at appliance placement (treatment commencement), the first half of treatment is worth 50% of the total fee, and the remaining 25% is allotted to the second half of treatment. Refunds or charges upon transfer will solely be based on this.

Verification

Please click on the human verification checkbox before submitting your form.