Hamilton City Dental Xray Release -

Hamilton City Dental

182 JACKSON STREET EAST
HAMILTON, ON, L8N1L4

Phone: (905)526-1322

Fax: (905)526-7100

E-mail:debenettidds@gmail.com

Please have all current and panoramic radiographs mailed or emailed to the address above

Hamilton City Dental Xray release

Patient Name

Former Dentist’s Name

Former Dentist’s Phone Number

Signature Of Patient or parent/gaurdian

Date

Date Of Last Complete Exam

Date Of Last Periapical

Date of Last Bitewings:

Date of Last Panoramic: