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: Date Format: MM slash DD slash YYYY Recent FMS:Recent Pan:Recent BW’s:Last Recall Exam: Date Format: MM slash DD slash YYYY Last Hygiene Appointment: Date Format: MM slash DD slash YYYY Date: Date Format: MM slash DD slash YYYY Patient/Parent/Guardian Signature: