X-Ray Release Form - Avyan Dental

X-Ray Release Form
Patient Name
Date

MonthDayYear
Date
Phone No
Format: (000) 000-0000.
Other family member to transfer:
Previous Dental Office Name
Phone No
Format: (000) 000-0000.
Please forward any radiographs and/or photographs taken to Dr. Manisha Chauhan.

Email: info@avyanfamilydental.com

I hereby give you consent to release all of my dental records to Dr. Chauhan at Avyan Family Dental.
Signature
Date

MonthDayYear
Date
Should be Empty: