Request for X-ray new patient form

Silver Dental Centre
510 Richardson Avenue

Ottawa ON K2B 5H1

T- 613-829-5921

F- 613-829-2088

silverdental@rogers.com
To (previous dental office):
Fax number:
I, First Name Last Name Authorize you to provide my dental records to The Silver Dental Centre. Please send all copies to the above email address. Thank you
*TO BE FILLED BY PREVIOUS DENTIST*

Please continue to signatures below
Date of Last Complete Exam
Date of Last Recall Exam
Date of Last Prophy/Fluoride
Copy of Panorex:

Yes No
Copy of X-rays

Yes No
Patient Signature

Clear
Date:

Month Day Year
Date
Witness Signature:

Clear
Date

Month Day Year
Date
Should be Empty:

Silver Dental Centre