X-RAY RELEASE

Newcastle

1-50 Mill Street North, Newcastle ON

Phone (905) 987 5858 Fax (905) 987 5893 appletreenewcastle@gmail.com

Bowmanville

6/7- 1550 Bowmanville Avenue, Bowmanville ON

Phone (905) 623-3938 appletreebowmanville@gmail.com

Name of Patient*

First NameLast Name
Date of Birth

MonthDayYear
Date
Date

MonthDayYear
Date
Name of Previous Office *
I, {nameOf} authorize any radiographs from the past 2 years, and all records to be forwarded to Apple Tree Dentistry at your earliest convenience.

Please include dates of the last NPE, PAN, RECALL and BW's for the above mentioned and the following family member(s);
Name(s) of additional family members
Signature of patient/parent/guardian*

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Should be Empty: