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*
Signature*