X-Ray Release Form - Lakewood Ranch Dental

X-RAY RELEASE FORM

Phone: (941) 907-8300 or Fax:(941) 907- 8206

	From: Lakewood Ranch Dental

	Page: 1

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Please send x-rays as attachments in Dexis, jpeg, png or pdf format and include exact date films were taken. Thanks 🙂

To whom it may concern,

I, , hereby grant permission for 's office to release any information related to my dental history and treatment, along with copies of my x-rays to:

Email: Smile@lakewoodranchdental.com
If possible we prefer x-rays by email over regular mail.

Signature:

PATIENT FORM

We bring premier dental care to our community one smile at a time. Dr. Kanter and his professional staff offer comprehensive and affordable quality dental care which means you won’t spend extra time and money driving around for the services you need because you can get most of your treatment conveniently and masterfully completed under one roof.

NEW PATIENTS

PRINT PDF
FILL ONLINE

ESTABLISHED PATIENTS

PRINT PDF
FILL ONLINE

ADDITIONAL FORMS

X-RAY RELEASE FORM
SLEEP APNEA SCREENING TEST

Mon:	08:00 am – 05:00 pm
Tue:	08:00 am – 05:00 pm
Wed:	08:00 am – 05:00 pm
Thu:	08:00 am – 05:00 pm
Fri:	08:00 am – 04:00 pm
Sat:	closed
Sun:	closed