Xray and Information Release Previous Dentist Name: Previous Telephone Number:Previous Office Fax /Email: This is release of dental xrays for: Please send original xrays if possible, as well as the dates of particular procedures and services.Date of last NPE: MM slash DD slash YYYY Recent FMS: Recent Pan: Recent BW’s: Last Recall Exam: MM slash DD slash YYYY Last Hygiene Appointment: MM slash DD slash YYYY Date: MM slash DD slash YYYY Patient/Parent/Guardian Signature:CAPTCHACommentsThis field is for validation purposes and should be left unchanged.