I, First Name Last Name , hereby authorize and request the release of x-rays taken of me to:Dentist / Dental Office Street Address Address Line 2 City State Zip Phone Number Digital Copy: Email By selecting Digital Copy you take full responsibility that the private dental records are going to be sent over the Internet without security and the ability to verify that receiving party successfully obtained the files. Furthermore, there is an understanding that the file format may not be compatible. We issue all x-rays in JPEG format. I understand that the X-rays are part of the original dental records that belong to TF Dental Group LLC the parent company of the dental office. We require 1 week from the time of signature to process your request. Please note that this form MUST be filled fully including your Signature, Date & Time, and the Drivers License Number that matches your original number when originally given to the practice.Patient's Signature: Signature Date & Time of Request: Date Time AM PM Driver License #: Type a label