Dental Records Release Form

RELEASE TO:

Westsprings Dental
15, 8 Weston Drive SW Calgary AB T3H 5P2
403-686-7266
westspringsdental@shaw.ca

By signing this form, I authorize

to release my dental records to Westsprings Dental.

RECORDS REQUESTED:

(  X  )  Most recent BW’s

(  X  )  Most recent anterior PA’s

(  X  )  Last PAN, any age