X-ray Request - Release

Date:

Month Day Year
Date
Name

First Name Last Name
DOB:

Month Day Year
Date
Authorize the office of:
Previous Dentist or dental office name:
Previous office name
to release my dental records and all sets of x-rays to Presidio Dental, office of Dr. Jesse C. Engle, DMD.
Digital charts or x-rays should be e-mailed to office@presidiodental.com.
Thank you,
Signed:

Patient's signature Clear
Should be Empty: