X-Ray Release Form
Please fill out this form to release your x-rays to a new dental office
Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
I hereby request the release of my current x-rays by:
Email
Printed and mailed ($15 fee)
Reason for release
SEND TO: Name of dental office/dentist
Office Email Address
example@example.com
Office Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Signature
Submit
Should be Empty: