X-‐RAY R elease F orm
I,______________________________hereby a uthorize a nd r equest t he r elease o f x -‐rays t aken o f m e t o:
( Please P rint )
M e ( The P atient)
ADDRESS:_____________________________________________________________________________
CITY/STATE/ZIP___________________________________________ P HONE:______________________
D entist/Dental o ffice
ADDRESS:_____________________________________________________________________________
CITY/STATE/ZIP___________________________________________ P HONE:______________________
D igital C opy
Email A ddress:_________________________________________
By s electing D igital C opy y ou t ake f ull r esponsibility t hat t he p rivate d ental r ecords a re g oing t o b e s ent o ver t he I nternet
without s ecurity a nd t he a bility t o v erify t hat r eceiving p arty s uccessfully o btained t he f iles. F urthermore, t here i s a n
understanding t hat t he f ile f ormat m ay n ot b e c ompatible. W e i ssue a ll x -‐rays i n J PEG f ormat.
I u nderstand t hat t he X -‐rays a re p art o f t he o riginal d ental r ecords t hat b elong t o T F D ental G roup L LC t he p arent c ompany o f
the d ental o ffice. W e r equire 7 2 h ours f rom t he t ime o f s ignature t o p rocess y our r equest.
Please n ote t hat t his f orm M UST b e f illed f ully i ncluding y our S ignature, D ate & T ime, a nd t he D rivers L icense N umber t hat
matches y our o riginal n umber w hen o riginally g iven t o t he p ractice. P lease e mail t he c ompleted f orm t o x .
Patient’s S ignature:_____________________ O ffice y ou v isited( C heck o ne)
Date& t ime o f r equest:__________________ H iram S tonewalk
Driver L icense # & D OB:________________________ M cDonough T ech
Acworth
Reason F or R elease:
S econd O pinion M oving I nsurance C hange N ot H appy w ith P ractice