X-Ray Release Form
I, (Patient Name)
First Name
Last Name
...Give authorization for Elite Dental & Denture PC to release my dental x-rays to the office of
Office name
...for my continued treatment or to myself, the patient.
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Patient name
Patient signature
Submit
Should be Empty: