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4300 S Park Dr #270, Stony Plain, AB T7Z 2W7
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X-Ray Form Form
Dental Radiograph Release Form
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Previous Dental Office Name
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Previous Dental Office Phone
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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
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Last Name
Patient Date of Birth
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