www.mountroyaldental.com - Consent to Release / Request Dental Records Form Logo
  • Consent to Release / Request Dental Records

  • I * , Consent and authorize Dr.   *   to release my current and previous dental records, including any information from other dental practitioners, to Dr. Sam Gupta, DDS.

  • All recent x-rays including BW's, Panorex, FMX/PA's

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  • Copies of Periodontal charting

  • Clear
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  • Should be Empty: