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Mount Royal Dental
2043 Mount Forest Drive, Burlington, Ontario L7P 1H4, Canada.
New Patients: (905) 581-9912 | Existing patients: (905) 332-4000


  Last name

  Mid name

  First name

Consent to Release/Request Dental Records

I, , Consent and authorize Dr. , to release my current and previous dental records, including any information from other dental practitioners, to Dr. Sam Gupta, DDS.
-  All recent x-rays including BW's, Panorex, FMX/PA's
-  Date of last recall/recare examination:
-  Date of last Scaling:
-  Copies of Periodontal charting
-  Recall Interval: 6 Months 9 Months
-  Scaling interval recommended: 3 Months 4 Months 6 Months 9 Months Annually
Other concerns or comments:
*Signature:
Date:
(Your digital signature (full name) is as legally binding as a physical signature.)