X-Ray Release Form

To release health care information of the patient name above, to:

Bow River Dental Centre
Address: #104, 30 Bow Street Common,
Cochrane, Alberta, T4C 2N1
Phone: 403-932-9889

This request and authorization apply to:

• Copy of complete dental chart including periodontal measurements
• Copy of dental x-rays (including Panoramic or FMS)

I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

Please note, the Supreme Court of Canada has ruled:

“A patient is entitled to copies of their dental records provided a signed authorization is received….”

Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.