North Arbor Dental
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.
Signature
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