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Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
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X-Ray Release Form
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Maintaining A Healthy Smile
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Periodontal Health
Menu
Who We Are
Our Clinic
Our Team
Dr. Jagatjit Dhillon
Dr. Amardeep Gill
Dr. Do Sung
Our Forms
New Patient Form
X-Ray Release Form
How We Can Help?
Maintaining A Healthy Smile
How Can I Sleep Better?
Fill Your Cavities
Replacing Missing Teeth
Children’s Dentistry
Restoring your smile
Protect Cracked Teeth
Control Gum Disease
Straighten Your Crooked Teeth
Services We Provide
Orthodontics
Invisalign
Braces
Myobrace
30 Second Smile Test
General Dentistry
Exam
Hygiene
Fillings
TMJ Treatment
Patient Scanning
Teeth Whitening
Emergency Dentistry
Dental Hygiene
Periodontal Health
Book Now
X-Ray Release Form
"
*
" indicates required fields
Dental Radiograph Release Form
Today's Date
*
DD slash MM slash YYYY
Previous Dental Office Name
*
Previous Dental Office Phone
*
Consent
*
I hereby authorize the release of my family's dental radiographs from my previous dental clinic so that they can be transferred to Dental Now Panorama.
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
Patient Date of Birth
*
Day
Month
Year
Signature
*
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