X-Ray Release Form

Permits X-ray release from Greenwoods to other facilities

Date

Patient

Date Of Birth

Patient Email

I hereby request that my dental x-ray(s) including all charting notes and preauthorizations be transferred from Greenwoods Dental Center to the office below:

From

Select a place

Location: (Clinic/Facility name where x-ray(s) to be transferred)

Email/Fax: (Clinic/Facility fax or email address where x-ray(s) to be transferred)

This authorization permits Greenwoods Dental & Surgical Centers to release all my information to a third party via regular email and/or fax without requiring any further consent from me.

Signature

According to rules set out by the Dental Association, x-rays are transferred on a shared bassis only. X-Rays are to be returned promptly after treatment is complete. Charges for duplicate forms and shipping may be applicable.