X-Ray X-Ray Release Form Release Form

X-Ray Release Form
Name*

First NameLast Name
Birth Date*

MonthDayYear
Phone Number*
Format: (000) 000-0000.
Select a Reason*
SelfNew Office
Patient Information
How would you like to recieve your x-rays?*
3D x-rays MUST be picked up from the office.
Address

Street Address

Apartment Number

CityState

Zip Code
Email
example@example.com
Appointment
New Office Information
Office Name
Phone Number
Format: (000) 000-0000.
Email
example@example.com
I, First and Last Name* , authorize Vast dental to release my dental x-ray records to the chosen option(s)
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: