X-RAY RELEASE FORM
Name
*
First Name
Last Name
Please forward my/our x-rays to Dr
*
Phone Number
*
Please enter a valid phone number.
Fax Number
Please enter a valid phone number.
Email
*
example@example.com
In addition to myself, please include the following members of my family:
Member 1
Member 2
Member 3
Member 4
Reason for Transfer
*
New Dentist
Referral to Specialist
Date
*
-
Month
-
Day
Year
Date
Print Name
*
By signing below, I authorize you to release my dental records/radiographs. In addition to this, by signing this form you release McCall Dental from all legal responsibility that may arise and confirm that my account is at a zero balance.
*
Continue
Continue
Should be Empty: