X-Ray Release Form
Permits X-ray release from Greenwoods to other facilities
CONTACT US AT 1-866-774-0006 FOR ASSISTANCE
Date
Patient
Patient Email
Date Of Birth
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
Clear 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.
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