X-RAY AND CHART TRANSFER AUTHORIZATION FORM

I authorize you to furnish any dental x-rays including all Panorex, any bitewing, and periapical(s) up to two years old to Aspen Springs Dental Centre. Please provide us with the dates of the following information.

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

Name *

Name of the Current Dentist / Dental Office (Write NA if not known *

Phone Number of the Current Dentist / Dental Office (Write NA if not known) *

Signature *

clear

Today's Date * +