Date

Patient

Date Of Birth

Patient Email

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

Dental Office/Facility Name

Dental Office/Facility Phone

To: (GWD location where x-ray(s) to be transferred)

Select a place

Email: (GWD location email address where x-ray(s) to be transferred)

Documents

Supported formats: PDF, DOC, DOCX, JPG, JPEG, PNG, GIF, TIF, TIFF (Max 10MB per file)

Signature

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