Records Share

Records Share

Upload your digital copies of panoramic and cephalometric x-rays and photos of the face and teeth.
This form allows you to securely upload your digital files of panoramic and cephalometric x-rays and photos of the face and teeth.

Please submit the digital records while you are registering so we can add them to the patient record and have them ready for review before the consultation.

The records file(s) you upload through this form must correspond to the patient identified on this form. To submit records for a different patient, please complete a separate Share submission. If file(s) for multiple patients are submitted through a single form, you will be asked to resubmit each patient's records separately.
Patient Name*

patient first namepatient last name
1 file2 files3 files
You may upload up to 3 files for the patient identified on this form. If you have more than 3 files, please provide the additional files through another Share submission.*

Upload up to THREE files for the patient identified on this form.
Cancelof
Name of file # 1. (Please enter the exact name of the file you uploaded. Do not rename the file.)*
name of file # 1
Date of file # 1. (This is the date the record was made or taken. For example: the date an x-ray was taken.)*

MonthDayYear
date of file # 1
Name of file # 2. (Please enter the exact name of the file you uploaded. Do not rename the file.)*
name of file # 2
Date of file # 2. (This is the date the record was made or taken. For example: the date an x-ray was taken.)*

MonthDayYear
date of file # 2
Name of file # 3. (Please enter the exact name of the file you uploaded. Do not rename the file.)*
name of file # 3
Date of file # 3. (This is the date the record was made or taken. For example: the date an x-ray was taken.)*

MonthDayYear
date of file # 3
Please provide your name- the name of the person completing this form.*

your first nameyour last name
Please provide your phone number so we can reach you should we have questions.*
your phone number.Format: (000) 000-0000.
Please provide your email address to receive a confirmation of form submission.*

Confirmation Emailyour email address
Should be Empty: