Lasalle Dental Patient's Information Release Form (check good to go)

Patient's Name

First NameMiddle NameLast Name
Birth Date

MonthDayYear
New Patient Exam

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last Recall Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Last Dental Visit

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Scaling (Units)
Did you take any Bitewings in the last 5 years?
Please specify the date of the last Bitewing

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Upload (Last available X-Ray, regardless of date)

Cancelof
Did you take a Panorex in the last 5 years?
Please specify the date of last Panorex

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please Upload (Please transfer all recent x-rays even if 5 years old)

Cancelof
Concerns & Comments
Should be Empty: