Release Form For Dental X-rays
To Whom It May Concern
*
I give permission to release all my dental records to the office of Natural & Cosmetic Dentistry
Email (to send X-Rays to):
healthysmiles@bcarlsondds.com
Signature
*
Clear
Name
*
First Name
Last Name
Date
*
-
Month
-
Day
Year
Date
Submit
Should be Empty: