Help Us Get Your X-Rays!

Thank you for being a Smiles patient!

Use this form to give us permission to ask your previous dental office for your x-rays. 

Smiles Dental X-Ray Release Form

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

Patient Name(Required)
Sex(Required)
Which Smiles Clinic Do You Attend?(Required)
Patient Address(Required)
Reason for Request:(Required)

From Their Previous Dental Office:

Date(Required)
Clear Signature