Authorization for Release of Dental Records and Radiographs
I, *
hereby authorize
(previous dental office) to release of my / my family’s dental records, radiographs and any additional information that would be beneficial to my dental care to Dr. Ajay Goyal & Dr.Sonam Goyal
Additional Family members:
Please list the date of the following:
NPE
Recall
Scaling
Panoramic
Bite-wings
Please forward at your earliest convenience.
Patient Signature
Date
167 Worthington St. E. | North Bay, ON | Phone: 705-472-7260 | dentistryonworthington@gmail.com | Fax: 705-495-0965
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