I First Name Last Name hereby authorize and request the release of x-rays taken of Type a label to: Type a label , Email: Email By selecting Digital Copy, you take full responsibility that the private dental records may be send over the Internet without security and the ability to verify that receiving party successfully obtained the files. Furthermore, there is an understanding that the file format may not be compatible. We issue all x-rays/chart in PDF and or JPEG format. I understand that the X-rays are part of the original dental records that belong to Manhattan Best Dental Care Office. We require 72 hours from the time of signature to process your request excluding weekends and holidays. Please note that this form MUST be filled fully including your Signature, Date & Time, and the Driver’s License Number that matches your original number when originally given to the practice. Please email the completed form to manhattanbestdentalcare@gmail.com. Also, there is a $15 fee payable online https://pay.balancecollect.com/m/manhattanbestdentalcare