X-Ray and Information Release Form

X-Ray and Information Release Form

DENTAL OFFICE: Please email X-rays to:

or mail to: Brantford North Dental, 525 Park Rd. North #102, Brantford, ON N3R 7K8

I, Type your full name here, authorize the release of any records and/or x-rays to Brantford North Dental, pertaining to:
(Please choose one or both)

MyselfThe following individuals for whom I am responsible:
The following individual(s) for whom I am responsible:
First Name   Last Name
First Name   Last Name
First Name   Last Name
First Name   Last Name
First Name   Last Name
Dental Office Contact Information

Please provide the contact information from the dental office that will be sending the records:
Name of Dental Office
Area CodePhone Number
Please complete as much information as you have available to you:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date*

MonthDayYear
Date
Patient please sign here:*

Clear
Should be Empty:

Dental Office Contact Information