Millway Dental

Relase of Records Consent Form

3200 Erin Mills Parkway, Mississauga, ON, L5L 1W8      905-607-4333

Patient's Name:
E-mail Address

I authorize you to release the most recent radiographs (Bitewings/PAN/Periapical’s/full mouth series).

Kindly provide the following:

  • Last Complete Examination (01101,01102,01103)
  • Last Bitewings (02142) or last Full Mouth Series
  • Last Recall Examination (01202)
  • Last Recall Polishing (11101, 11111)
  • Any other pertinent information

Please forward records to the office of:

Dr. Mohammad Hatamian
3200 Erin Mills Parkway
Mississauga, ON, L5L 1W8


Patient Consent