X-Ray Form Form

Dental Radiograph Release Form
Today's Date*
Day
Month
Year
Previous Dental Office Name*
Previous Dental Office Phone*
Consent
I hereby authorize the release of my family's dental radiographs from my previous dental clinic so that they can be transferred to North Stony Dental.
Panorex within the last 5 years
Bitewings within the last 2 years
Periapical radiographs within the last 2 years
Patient Name*
First Name Last Name
Patient Date of Birth*
Day
Month
Year
Signature*

Dentistry Made Simple.

Our family-friendly Stony Plain dentists are located near the Stony Plain Safeway. Book your appointment today.

Spruce Grove Alberta and Stony Plain Dental Clinic
Company	North Stony Dental
Services	Dentistry, Orthodontics, Invisalign, Emergency Dental, Myobrace
Founded	2017
Area Served	Spruce Grove and Stony Plain
Pricing	$$