X-Ray Release Form

X-RAY RELEASE FORM

Name:(Required)

Date:(Required)

Previous Name:

I request and authorize Dr.(Required)

Phone:

To release health care information of the patient name above to:

Toothcrew Family Dental

#304 ,11420 27 Street SE Calgary , Alberta T2Z 3R6

(587)358.3333

This request and authorization apply to:

Copy of complete dental chart including periodontal measurements
Copy of dental x-rays (including Panoramic or FMS)

I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.

Print Patient or Patient's Authorized representative:(Required)

Date of Birth:(Required)

Signature of Patient(Required)

Relationship of status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)

CAPTCHA

Name

This field is for validation purposes and should be left unchanged.

Thank you for considering Toothcrew Family Dental. We look forward to meeting you!

We will reply to your request as soon as possible during business hours. If your inquiry is received after business hours, we will respond during our next business day.

Messages sent using this form are not considered private. Please contact our office by telephone at (587) 358-3333 if you are sending highly confidential or private information. Please review our privacy policy and website terms of use before submitting your form request.

X-Ray Release Form

Thank you for considering Toothcrew Family Dental. We look forward to meeting you!

Your Smile, Our Priority Experience exceptional dental care with Toothcrew Dental. Book an appointment or call us now to embark on your journey towards a healthier, brighter smile.

Let's get social Follow us on

TikTok

Instagram

Facebook