Request for X-Rays and Records

To serve you as best we can, please fill out your information below. All information will be strictly confidential.

Blue Quill Dental Centre
294 Saddleback Road, Edmonton, AB T6J 4R7
ph: 780.436.6971 fax: 587-906-8999
www.bluequilldental.com

Blue Quill Dental Centre is requesting the release of dental records for the patient named below. Please complete this form and we will forward your request to your previous dental office.

Your previous dental office

The office we should request your records from.

Office name(Required)

Office address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Office phone(Required)

Office email(Required)

Patient information

Patient name(Required)

First Last

Date of birth(Required)

Phone(Required)

Email(Required)

Records requested

Blue Quill Dental Centre is requesting the following for the patient named above. Please advise us of the date of the most recent of each, and forward any relevant radiographs:

Complete exam
Recall
Bitewings (BW)
Panoramic (PAN)
Full mouth series (FMX)

Please forward radiographs and the above information to our office at your earliest convenience. Digital radiographs may be emailed to admin@bluequilldental.com.

Authorization

I, the patient named above, authorize the release of my dental records to be sent to Blue Quill Dental Centre. I understand that in transferring my records, I am granting access and communication of my personal and medical information.

Are you signing on behalf of the patient?(Required)

No

Yes

Print name of authorized representative(Required)

Print source of representative's authority(Required)

For example: parent, legal guardian, power of attorney.

Please sign below to authorize the release of these records.