X-Ray Release Form

Dental Radiograph Release Form
Today's Date*
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*
Signature*

Dentistry Made Simple.

Thanks For Filling In Our Form.

Our Hours

Weekday	Our Hours
Monday	12 – 7:30p.m.
Tuesday	7:30a.m. – 7:30p.m.
Wednesday	7:30a.m. – 7:30p.m.
Thursday	9a.m. – 4:30p.m.
Friday	8a.m. – 3:30p.m.
Saturday	9a.m. – 3:30p.m.

Closed on holidays and long-weekends.