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Dr. Alexandra Moore
Dr. Aaron Mah
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Menu
Who We Are
Dr. Jagatjit Dhillon
Dr. Alexandra Moore
Dr. Aaron Mah
How We Can Help
General Dentistry
Dental Exam
Dental Implants
Root Canal
Tooth Removal
Emergencies
TMJ Therapy
Sedation Dentistry
Cosmetic Dentistry
Teeth Whitening
Veneers
Crowns and Onlays
Bridges vs Implants
Orthodontics
Invisalign
Braces
Myobrace
Snore Centre
Hygiene
Office Forms
New Patient Form
X-Ray Form
COVID-19 Consent Form
Schedule Your Appointment
Contact Us
X-Ray Release Form
Dental Radiograph Release Form
Today's Date
*
Date Format: DD slash MM slash YYYY
Previous Dental Office Name
*
Previous Dental Office Phone
*
Consent
*
I hereby authorize the release of,
My entire family's dental radiographs from my previous dental clinic so that they can be transferred to Beacon Smiles Dental.
Panorex within the last 5 years
Bitewings within the last 2 years
Periapical radiographs within the last 2 years
Patient Name
*
First Name
Last Name
Patient Date of Birth
*
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Signature
*