Request for X-ray new patient form

Record and X-ray Release Form
Name of Previous Dental Office: *
Fax Number or Email of Previous Dental Office:*
I, First Name* Last Name* Authorize you to provide my dental records to Silver Dental Centre. Please send all copies to the above email address. Thank you
Patient Signature*
Today's Date:*

MonthDayYear
Date
Should be Empty:

Record and X-ray Release Form