Innovation Dental Form

Date:

To:

From: Innovation Drive Dental

Re: Request for Patient Records

To Whom It May Concern,

I Mr./Mrs./Miss hereby request and authorize the release of my / my family’s dental records and radiographs to Dr. Jennifer Shulman and/or Dr. Corey Shulman of Innovation Drive Dental Office.

Signature:

I agree that the electronic signature above will be an electronic representation of my signature for all purposes, just the same as pen-and-paper signature.

Please email x-rays to:
Info@innovationdrivedental.com

As per RCDSO Guidelines: Patients have the right of access to a copy of their dental records. Please honour the above request in a timely manner for forwarding:

Copies of original files of most recent full-mouth series, panoramic film taken within the last 24 months. Furthermore, kindly provide us with the following information in order to help us in serving this patient’s dental needs.

Date of new patient examination:

Date of last recall examination:

Date of last bitewing radiographs:

Date of last panoramic/fms radiographs:

Your co-operation is greatly appreciated. Thank you.

Innovation Drive Dental
20 Innovation Drive, Unit 2
Woodbridge, Ontario L4H 0T2

905.264.0333

905.264.7033 fax

Answer: 6+4=