X-Ray Release

X-RAY RELEASE FORM

Name:

Date of Birth:

Previous Clinic:

I request and authorize Dr.

Phone:

To release health care information of the patient name above, to:

Ultima Dental Wellness

Suite 202, 506 - 71 Avenue SW

Calgary, AB, T2V-4V4

Phone: (403) 259-3401 | Fax: (403) 253-9791

Email: info@ultimadentalwellness.ca

This request and authorization apply to:

Copy of complete dental chart including periodontal measurements
Copy of dental x-rays (including Panoramic or FMS)

I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.

Patient Name or Patient's Authorized representative:

Date:

Signature:

Relationship of status if signed by anyone other than the patient (parent, legal guardian, personal representative, etc.)

78179

The Ultima Dental Wellness team is committed to working together to ensure that every patient who visits us has an experience that exceeds their expectations, each and every time!

Quick Links

Practice Hours

Our
Practice Hours

Monday: 8:00 am to 3:00 pm

Tuesday: 9:00 am to 6:00 pm

Wednesday: 9:30 am to 6:00 pm

Thursday: 7:00 am to 4:00 pm

Friday: 8:00 am to 4:00 pm

Saturday: By Appointment Only

Sundays: Closed

Statutory Holidays: Closed

Contact Us

#202, 506 – 71 Avenue SW
Calgary, Alberta
T2V 4V4

(403) 259-3401 info@ultimadentalwellness.ca

Disclaimer

The dentists at Ultima Dental Wellness are all General Dentists. As general dentists, they provide cosmetic dental procedures such as porcelain veneers, dental crowns, dental braces, and teeth whitening as part of their General Dentistry license. Cosmetic Dentistry & Family Dentistry are not recognized dental specialties by the Alberta Dental Association & College of Dental Surgeons of Alberta (CDSA). As SW Calgary Dentists, they provide General Dental procedures for all ages within the family.

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