www.humbervalleydental.com - Information Release Form

Information Release Form
Dear Dr.
Phone Number*
Please enter a valid phone number.
Fax Number
The following patient/patients are now attending our office for dental care.
They have requested your office to send all records and x-rays for the last 2 years:

PLEASE REPLY WITH DATES OF EACH X-RAY.
Date of Complete exam

MonthDayYear
Date
Date of Last Recall

MonthDayYear
Date
Date of Last Bite Wings+ date

MonthDayYear
Date
Periapical x-rays
Date of Last PAN+ date

MonthDayYear
Date
Information and x-rays to be emailed to reception@humbervalleydental.ca
I hereby release you from all legal responsibility or liability that may arise from this authorization:
Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Humber Valley Dental
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25 Queen Street North
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Bolton, Ontario L7E 5T3
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New Patients (289) 536-4498
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Existing Patients (905) 857-3398
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Fax 905-857-1433
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www.humbervalleydental.ca
Should be Empty:

Information Release Form