Dental Radiograph Release Form

98 Queen Street West, Brampton, ON L6X 1A4 905-457-4445

The information in this form is CONFIDENTIAL and enables our office to provide the highest level of care and service possible. Please complete all forms as completely as possible. Thank you.

Patient's Name:

E-mail Address

Phone Number:

(Please write the names of all family members below)

Previous Dental Office:

Office Phone #:

Consent and Authorization

I hereby authorize the release of my family’s dental records including all radiographs from my previous dental clinic so that they can be transferred to My Smile Dentistry.