Grace Dental 12425 55th St N Lake Elmo, MN 55042 phone 651

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Grace Dental 12425 55th St N Lake Elmo, MN 55042 phone 651
Grace Dental
12425 55th St N
Lake Elmo, MN 55042
phone 651 430-1020 fax 651 439-2201
[email protected]
Request for transfer of Patient Information. Today's date:
Attn: Previous Clinic Name
please print
Patient(s) name(s)
DOB
/
/
DOB
/
/
DOB
/
/
Please forward current x-rays, patient history, unfinished treatment
plans and current specialist correspondence to the following dental
clinic: Grace Dental at the address above
Dates of last Exam
Prophy
BWX
FMX
check if this request needs immediate attention due to an
appointment soon.
Date of appointment
Signature of authorized requestor

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