X-RAY Release Form

X-RAY Release Form
Patient Name
First NameLast Name
Reason for release
Second OpinionMovingInsurance ChangeNot Happy with PracticeOther
Release X-Ray to:
Me (Patient)Dentist/Dental officeDigital EmailOther
Patient Mailing Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Patient Phone Number
Please enter a valid phone number.
Dental Office Mailing Address
Street Address
Street Address Line 2
CityState / Province
Postal / Zip Code
Dentist Phone Number
Please enter a valid phone number.
Email
example@example.com
By selecting Digital Copy you take full responsibility all the risks such that the private dental records are going to be sent over the Internet without security.
Furthermore, you should understand that the file format may not be compatible. We issue all x-rays in JPEG format.
You should also understand that the X-rays are part of the original dental records that belong to the parent company of the dental office. We require 72 hours from the time of submit to process your request.
Date
MonthDayYear
Date
Signature
Clear
Should be Empty: