• Background photo for Pediatric dentist Dr. Brian Richards - Transfer Request page

TRANSFER REQUEST

First and Last Name:
Street Address:
Apartment Number:
City:
State/Province:
Zip/Postal Code:
Email:
If you are transferring from another Dentist's office, please leave the following information so we can transfer your records to our office.
Patient's Name:
Name of Previous Dentist:
Dentist's Phone:
Dentist's Email:
Comments/Questions:

Please type "123" in the box below to validate your submission.