X-Ray Release Form

Dear Dr.

Dr. Samira Jaffer, and the patient listed below, would like to thank you for the professional care that you have shown in the past and ask that in order to ensure continuity of such care that the past x-ray films ( in the last 5 years) and treatment records be forwarded to this office.

All information received will, of course, be held in the strictest of confidence for the patient. Diagnostically- acceptable films and photocopies of written records are requested.

I hereby authorize the release of my records as requested by Concourse Dental Group: