Record Release X-rays and Dental Records Release Form Attention (Name of previous Dentist/Dental Clinic) * Phone, Fax or E-mail * I authorize the release of dental records, including medical and dental history, treatment records, and radiographs for the following patient(s) to the office of Dr. Mahawish Fatima Zaidi and Associates (East End Dental Centre) 1. Patient Name Date Of Birth 2. Patient Name Date Of Birth 3. Patient Name Date Of Birth 4. Patient Name Date Of Birth 5. Patient Name Date Of Birth Records Requested w/ Dates Patient Name Bitewings PAN FMX New Patient Exam Last Recall Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text Text 613-767-0777 www.eastenddentalcentre.com info@eastenddentalcentre.com 760 Highway 15, Unit 2, Kingston, Ontario K7K 6X2 Patient/Guardian Signature signature keyboard Clear Submit If you are human, leave this field blank.
