• Responsible Party

  • To 

    {previousDentist18}

    {dentalPractice}

    {practiceLocation}

     

    I authorize the above Dentist to furnish my dental records, including x-rays and the last record of the requested treatment to:


    Rayside Dental
    Dr. Guillaume Racicot

    4764-34, REGIONAL ROAD #15
    CHELMSFORD, ON
    P0M 1L0
    Phone: 705-855-4449

    Fax: 705-855-0072

     

    Please send digital x-rays to inforaysidedental@gmail.com
    I release you from all legal responsibility or liability that may arise from this authorization.

  • Date
     - -
    2 digit month, 2 digit day, 4 digit year
  • Should be Empty: