X-Rays Release Form

Patient's Name

Date of Birth

Please send my child's most current x-rays via Email to:

Please cancel all future appointments I/we have at this time.

I/We plan to keep all current appointments scheduled at this time.

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.

Parent / Guardian Name / Signature

Date

*If there is a balance due on this account, please pay in full prior to the release of records.

Balance due:

Please allow 5 business days for processing after we receive this request

Your information will be encrypted.

X-Rays Release Form

Northern Michigan Pediatric Dentistry