X-Ray Request To Release Form | Dentists In Edmonton & Area Smiles Dental Group

Send Your X-rays

Use this form to request Smiles to release your X-rays to your new dental clinic.

This letter is to authorize the release of dental x-rays and records for:

Patient Name(Required)

First Last

Parent/ Guardian

Patient Email(Required)

Patient Phone(Required)

Date of Birth(Required)

Sex(Required)

Male

Female

Which Smiles Clinic Do You Attend?(Required)

Brintnell (North Edmonton)

Mill Woods

Sherwood Park

St. Albert

Spruce Grove

Secord (West Edmonton)

Calgary Trail

Patient Address(Required)

Street Address Address Line 2 City Province Postal Code Country

Add Any Family Members to this Request (Use the + Button to Add More)

Name

Date of Birth

To This Dental Office:

New Office Name(Required)

New Office Contact #

New Office Email:

Reason for Changing Clinics:(Required)

Additional Feedback:

Date(Required)

Signature(Required)

CAPTCHA

Dentists in Edmonton, Mill Woods, Spruce Grove, St Albert and Sherwood Park

Our Edmonton dentists offer a wide range of dental services such as cleanings, clear aligners, dental surgeries, wisdom teeth extractions, dental implants. We even offer elective esthetic dental procedures like porcelain veneers, tooth-coloured (mercury-free) fillings, in-office teeth whitening, as well as many others.

We Accept the Canada Dental Care Plan! Click Here to Learn More

We Accept the Canada Dental Care Plan (CDCP)! Click Here to Learn More

Send Your X-rays

This letter is to authorize the release of dental x-rays and records for:

To This Dental Office:

Dentists in Edmonton, Mill Woods, Spruce Grove, St Albert and Sherwood Park

Dental Clinics

Smile Dental Group