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X-Ray Release Form

X-Ray Release Form

This field is for validation purposes and should be left unchanged.
X-RAY RELEASE FORM
Date:(Required)

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.

Date of Birth:(Required)

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.