X-Ray Release Form

At this time, we are not accepting new patients. Please only complete this form if you’ve been asked to by our staff. If you are an existing patient, please contact the office at (613) 283-6870 to update your information.

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Patient Name*

First Last

Date of Birth*

MM slash DD slash YYYY

Patient Phone Number*

Previous Dental Office*

Dentist's Name*

Office Phone Number*

Are there any other family members that you would like to include in this release form?*

Yes

No

Patient Name 1*

First Last

Date of Birth*

MM slash DD slash YYYY

Patient Name 2

First Last

Date of Birth

MM slash DD slash YYYY

Patient Name 3

First Last

Date of Birth

MM slash DD slash YYYY

Patient Name 4

First Last

Date of Birth

MM slash DD slash YYYY

Consent*

I authorize you to release dental x-rays of all the above mentioned patients to Maple Dental via mail 24 Main St. W., Smiths Falls, Ontario K7A 1M5 or email admin@mapledentalsf.ca

Signature*