Xray Release - Family Dentistry @picton

Family Dentistry @ Picton

Our family caring for yours
DATE:

MonthDayYear
Date
Patient Name(s):
The above patient(s) would like to thank you for the care you have shown them in the past. In order to provide them with the same continued care, we would appreciate it if you would release their most recent radiographs and records. Where possible please send digital copies of x-rays. I authorize the release of my/our information to Family Dentistry @ Picton. Please provide the following information:
Patient Signature:
******************** TO BE FILLED OUT BY DENTAL OFFICE ********************
Date of last complete exam:

MonthDayYear
Date
Date of last recall exam:

MonthDayYear
Date
Date of last scaling/hygiene appointment:

MonthDayYear
Date
Date of last BW:

MonthDayYear
Date
Date of last PANOREX:

MonthDayYear
Date
Copies of referral letters from specialists or any other pertinent information.
Thank You,
Family Dentistry @ Picton
45 Main Street, Picton ON K0K2T0 (613)476-3466 phone (613)800-5200 eFax familydentistryatpicton@gmail.com familydentistryatpicton.com
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