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: Recent FMS:Recent Pan:Recent BW’s:Last Recall Exam: Last Hygiene Appointment: Date: Patient/Parent/Guardian Signature:Your NameYour NameYour NameYour Name
