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Mount Royal Dental


  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.)