Dental Record and Radiograph Release

To

Previous DMD/Office

Patient Information

Patient Name

Address

Phone

Date of Birth

Signature

I authorize the release of my dental radiographs (including my most recent BWX, Panorex or FMX) and a copy of my dental history to the following practice:

Dr. Brian P. Ganley, DMD Family Dentistry
134 Main Street, Unit 1C | PO Box 687
Groton, MA 01450
(978) 448-5523

Name of Patient

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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