X Ray release form

Permits X Ray release from Greenwoods to other facilities

Patient

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 location below:

Transfer

From (the Greenwoods location with your X Rays)

Choose a location

Location (clinic or facility receiving your X Rays)

Send my X Rays by

Fax

Clinic email (clinic or facility receiving your X Rays)

Signature

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 basis only. X Rays are to be returned promptly after treatment is complete. Charges for duplicate forms and shipping may be applicable.