Dental Radiograph Release Form

123 Pioneer Drive, Suite B210, Kitchener, ON N2P 2A3 519-748-9200

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 #:

Additional Information Requested to be released:

Date of last Bitewing radiographs:

Date of last Panoramic/FMS radiographs

Date of last Complete Exam (01103):

Date of last Recall Exam (01202)

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 South Kitchener Dentistry.