X-Ray Release Form

X-Ray Release Form
Today's Date*
DD slash MM slash YYYY
Previous Dental Office*
Previous Dental Office's Phone Number
Consent*
I hereby authorize the release
Of my family's dental radiographs from my previous dental clinic so that they can be transferred to Parkway Smiles Dental.
Panorex within the last 5 years
Bitewings within the last 2 years
Periapical radiographs within the last 2 years
Patient Name*
First Name Last Name
Signature*

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Visit Our Evanston Dental Clinic

2045 Symons Valley Pkwy NW #3010, Calgary, AB T3P 0Y2, Canada

(403) 452-2833

reception@parkwaysmiles.ca

Clinic Directions

2045 Symons Valley Pkwy NW #3010, Calgary, AB T3P 0Y2

403-452-2833

reception@parkwaysmiles.ca

How Our Dentists Can Help

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Communities Our Clinic Serves

Evanston

Livingston

Sage Hill

Carrington

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