X-ray Release Form

X-ray Release Form

X-ray Release Form
I hereby authorize Dr.*
to release my x-rays to: Jason P. Tosto, DMD
Please enter previous dental office contact information
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
___________________________________________

PLEASE EMAIL X-RAYS TO: schedule@2nd-opiniondental.com

If you have any questions or require further assistance, please feel free to contact our office.

Thank you,

Jason P. Tosto, DMD
Date*

MonthDayYear
Date
Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Signature*

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