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Information Release Form
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Information Release Form
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Information Release Form

1 Water St, Box 2027
Angus On
LOM1BO
Telephone: 705 424-0873, Fax: 705 424-4356

Information Release

I authorize you to furnish copies of the most recent radiographs (bitewing/pan/periapical/full mouth series) and photocopy of written records.

(Old office to fill in the information below and return to us)

(Please forward BW's/PA's if less than 1 yr old and panorex if less than 5 yrs old)

Please send records by email or fax to our office, we have provided the contact info above.

I release you from all legal responsibility of liability that may arise from this authorization.