• TOOTH CONNECTION DENTAL

  • Previous Dental Office Information

    Please provide the information for the dental office you would like us to request your records from.
  • Format: (000) 000-0000.

  • TOOTH CONNECTION DENTAL

  • To whom it may concern,

    I, *   *   hereby request and authorize the release and forwarding of any dental records and radiographs to Dr. Rachel Kitsopanidi.

    I hereby release you from any and all legal responsibility or liability that may arise from this authorization.

    Kindly include the dates for the following:

    • LAST RECALL EXAMINATION
    • LAST COMPLETE ORAL EXAMINATION
    • LAST FULL MOUTH SERIES OR PANOREX XRAY
    • LAST SCALING APPOINTMENT
    • LAST BITEWING RADIOGRAPHS

  • Thank you for your prompt attention and co-operation in this matter.

    Sincerely,

  • Date*
     - -

  • 7777 Weston Rd. Suite #218 Woodbridge Ontario L4L 0G9

    Fax: (905) 605-9006    E-mail: toothconnectiondental@hotmail.com

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