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X-Ray Release Form
"
*
" indicates required fields
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
*
Phone
This field is for validation purposes and should be left unchanged.
