Dental Radiograph Release Form

This form is to authorize the release of dental radiographs for*
(Patient Name)
Patient Phone Number*
Date of Birth*
YYYY dash MM dash DD
from*
(Dental Office)
to Dynamic Dental.
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to
The family members are the following:
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Request
Please have all current panoramic radiographs mailed/emailed to the address below: Dynamic Dental #210 163 Quarry Park Blvd, SE Calgary, AB T2C 5E1 PH: (403) 453-5588 Fax: (403) 453-5585 Email: info@dynamicdentalcalgary.com If the x-rays are digital please send us all of them regardless of the year taken. If the x-rays are hard copy please send us only what is current within one year. Thank you, Dr. Nikola Vranjes
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Recipient
Dynamic Dental #210 163 Quarry Park Blvd, SE Calgary, AB T2C 5E1 PH: (403) 453-5588 Fax: (403) 453-5585 Email: info@dynamicdentalcalgary.com
Patient Name*
Signature*
Signature Date*
YYYY dash MM dash DD
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