Records transfer

Request for X-rays and Dental Records

Complete this authorization so your previous dentist can transfer recent records to Cedar Crest Dental Care.

Please complete this before your appointment.

If no X-rays are received by your appointment, you may be responsible for the cost of current X-rays.

Your answers stay on this deviceThe completed PDF is created in your browser, sent over HTTPS to CCDC, emailed to the practice, and saved as an encrypted server copy.

Previous dental office

Tell us where the request should be directed.

Dentist or practice nameFaxEmail

Patient information

This helps the previous office find the correct chart.

Patient’s full nameDate of birthDate of requestAlso include records forList any additional patient names and dates of birth.

Authorization

Review where the records will be sent.

Please transfer my dental records and X-rays—especially panoramic or full-mouth X-rays taken within the last five years and bitewings taken within the past two years—to:

Cedar Crest Dental Care
1251 S. Cedar Crest Blvd., Suite 207C
Allentown, PA 18103
Digital records: info@ccdc.dentist

I authorize the previous dental office named above to transfer the listed records and X-rays to Cedar Crest Dental Care.I agree that typing my name below and selecting a handwriting style is my electronic signature, and I intend it to have the same effect as signing by hand.

Patient or legal representative electronic signatureType the signer's full legal name, then choose a handwriting style.

Choose a handwriting style

SignatureAlluraSignatureSacramentoSignatureGreat Vibes

The typed name, chosen style, signing time, and a SHA-256 signature integrity ID are included in the completed PDF. CCDC records a separate SHA-256 fingerprint of the submitted document, which is encrypted at rest.

Date signed

Submit your completed request securely

When you submit:

The completed PDF is created on this device.
It is securely sent to Cedar Crest Dental Care.
CCDC receives it by email and stores an encrypted server copy.

Please wait for a confirmation number before closing this page.