X-Ray Release Form

    Dr. Manisha Chauhan, DDS

    2160, 4 Royal Vista Way NW

    Calgary, AB T3R 0N2

    587-358-2160[email protected]

    Patient Name

    Other family members to transfer

    Previous Dental Office Name

    Please forward any radiographs and/or photographs taken to Dr Manisha Chauhan.

    Email : [email protected]

    I hereby give you consent to release all my dental records to Dr. Chauhan at Avyan Family Dental.