Dental Radiograph Release Form

31 Kingsbury Dr Suite 110, Kitchener, ON N2A 2L9 519-896-7779

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)

Date of last hygiene appointment:

Any restorative work done in last (2) years

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 North Arbor Dental.