SAMPLE LETTER
On Dentist Stationery

Dear :

Please be advised that due to ___________(reason) I am discontinuing the practice of dentistry on (DATE). I shall not be able to attend to you professionally after that date.

Please be advised of your need for continued care. I suggest that you arrange to place yourself under the care of another dentist. If you are not acquainted with another dentist, I suggest that you contact the Third District Dental Society at 518-782-1428 for a list of dentists in your area.

I shall make my records of your case available to the dentist you indicate on the "Authorization to Transfer Records". Your dental records are confidential and no transer will be made without your written authorization.

I am sorry that I cannot continue as your dentist. I extend to you my best wishes for your future health and happiness.

Very truly yours,


Signature
(Printed name)


Authorization to Transfer Records

Date:__________________

To: (Your Name)

I hereby authorize you to transfer or make available to Dr. __________________
Address:_________________________________________________
all my records and reports relating to my dental treatment.

Signed:______________________________


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