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
2 digit month, 2 digit day, 4 digit yearDate
Should be Empty:

Record and X-ray Release Form