X-Ray Request and Release Form

Date:
Patient Name:
Requested by (if other than patient):
Relationship to patient:
Dentist Name:
Office Tel number / Email address:
Dental X-rays requested: Please release my most recent FMX/PAN
I authorize the release of my dental X-ray(s) requested above. Please send a digital copy of requested X-ray(s) to info@mod-mouth.com.
Date:
Signature:

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