X-Ray Release Request

Previous Dentist Name:

Previous Dentist Email:

Previous Dentist Number:

would like to thank you for the dental care you have provided. I ask that in order

to preserve the continuity of care that you forward all current radiographs & clinical records to deepdentalclinics@gmail.com.

Please provide the dates of the following information to ensure optimal care:

01103

01202

02601

02142

Scale

FMS

I have given consent for the disclosure of this information and I request that my records be released.

Thankyou for your timely response

Patient Signature: