Permission To Release Dental Records and X-Rays

Permission To Release Dental Records and X-Rays

Thank you, we will get back to you as soon as possible. If you have any questions do not hesitate to call us. (905) 726 8213)
  • I give permission to release the dental records and X-rays of my child to Aurora Kids Dentistry.
  • This is the practice name where the records come from.
  • Name of the Doctor releasing the records.
  • Address of the practice where the documents come from.
  • MM slash DD slash YYYY

Aurora Kids Dentistry

Pediatric Specialty Office

Phone: (905) 726-8213