X-Ray Release Form - Lakeside Family Dental

X-Ray Release Form
To: Dr.
Office #
Fax#
I authorize the release of * field. Please email x-rays to info@lakesidefamilydental.ca or sent to the above address.
Please provide the following information and return with x-rays:
Patient Name*
Date of last N.P.E

MonthDayYear
Date
Date of last Recall

MonthDayYear
Date
Date of last Panorex

MonthDayYear
Date
Date of last BWS

MonthDayYear
Date
Patient Name
Date of last N.P.E

MonthDayYear
Date
Date of last Recall

MonthDayYear
Date
Date of last Panorex

MonthDayYear
Date
Date of last BW’S

MonthDayYear
Date
Patient Name
Date of last N.P.E

MonthDayYear
Date
Date of last Recall

MonthDayYear
Date
Date of last Panorex

MonthDayYear
Date
Date of last BW’S

MonthDayYear
Date
Patient/Parent Signature:*

Clear
Should be Empty: