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 Ilyas Ahmed D.D.S.
545 Steeles Ave West, Unit # 18
Brampton, ON l6Y 4E7

E-mail: contactus@drahmed.ca

I release you from all legal responsibility or liability that may arise from this Authorization.