X-Ray Release Form

{name-1-prefix} {name-1-first-name} {name-1-middle-name} {name-1-last-name} hereby request and authorize the release of my/my family’s dental records and radiographs to Unionville Gate Family Dentists at the above
address.

Thank you.

{name-1-prefix} {name-1-first-name} {name-1-middle-name} {name-1-last-name}