Dental X-Ray Release

Thank you for choosing 419 Dental for your dentistry needs. Please complete the form below before your x-ray appointment, and a member of our team will reach out if we have any questions. If you have any questions, please feel free to contact us.

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Dental X-Ray Release

Please fill out our release form in its entirety to ensure we can provide you with the best possible care.

Note: Any fields with * are required.

Name *

First

Last

Email *

I hereby authorize the doctor and staff of 419 Dental to release records or knowledge concerning my dental health to (select one): *

Given directly to me
Sent directly to a dental office (provide information below) (postage fee will apply)
Given to a guardian (if patient is a minor)

Purpose or need for which information is to be used: *

Transfer of Records to Doctors Office
Second Opinion
Other

AUTHORIZATION: I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this Authorization at anytime, except to the extent that action has already been taken to comply with it. *

I have read and understand

Signature *

Clear Signature

Date *

Dental X-Ray Release

Dental X-Ray Release

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