Radiant Dental of Bedford 902 Echo Vale Drive Bedford, PA 15522
To Pick up my records (Photo ID required)
When transferring information to another dental office we only send current x-rays (bitewing x-rays, full mouth x-rays & panorex) within the last 5 yrs and treatment dates for prophy’s (cleanings) – exams – scale & root planning.
If you want us to release other information then please mark below.
DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.
If signed by a person other than the patient, complete the following:
By signing, I understand that the information released per this authorization, if redisclosed by the recipient, is no longer protected by Radiant Dental of Bedford.
Your information will be encrypted.