Are you a new patient?

Fill in the information below so we can get your previous x-rays prior to your visit.

X-Ray Release Form

  • Dental Radiograph Release Form

  • Date Format: MM slash DD slash YYYY
  • Panorex within the last 5 years
    Bitewings within the last 2 years
    Periapical radiographs within the last 2 years
  • Date Format: MM slash DD slash YYYY