Due to some insurance companies only covering x-rays in a specific time frame please ask your old dental Clinic to email or fax any bite wing x-rays under a year old and any panorex under three yearsold. Please fill out the information below and email or fax back to your old Dental Clinic.
Name of releasing dental clinic:
Patient name:
DOB (MM/DD/YYY):
I authorize and request a copy of my dental x-rays to be released to:
North Main Family Dental #108, 400 Main Street North Airdrie, AB T4B 2N1 Phone: 4039800056 Fax: 403.980.1296 Email:office@northmainfamilydental.ca
Signature (if minor, have parents sign)
Date
Follows Fee Guide | Accepts CDCP
