X-Ray Request Form
Permits X-ray release from Other facilities to Greenwoods
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) be transferred to Greenwoods Dental Centers to the location below:
Dental Office/Facility Name
To:
(GWD location where x-ray(s) to be transferred)
Select a place
Dental Office/Facility Phone
Email:
(GWD location email address where x-ray(s) to be transferred)
Please also include any recent pre-approvlas received from the insurance carrier(s).
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