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Address!
367 Nolanridge Cresent NW, Calgary, AB
Call us!
587-864-4300
Email Us!
info@thedentalland.com
Why Dental Land
Our Team
Dr. Al-Gertani
Services
Family Dental
Emergency
Children Dentistry
Dental Hyg + Teeth Cleaning
Cosmetic
Crown & Bridge
Whitening
TMJ
Root Canal
Sedation
Patient Forms
New Patient Form
Dental Xrays Release
Blog
Why Dental Land
Our Team
Dr. Al-Gertani
Services
Family Dental
Emergency
Children Dentistry
Dental Hyg + Teeth Cleaning
Cosmetic
Crown & Bridge
Whitening
TMJ
Root Canal
Sedation
Patient Forms
New Patient Form
Dental Xrays Release
Blog
Why Dental Land
Our Team
Dr. Al-Gertani
Services
Family Dental
Emergency
Children Dentistry
Dental Hyg + Teeth Cleaning
Cosmetic
Crown & Bridge
Whitening
TMJ
Root Canal
Sedation
Patient Forms
New Patient Form
Dental Xrays Release
Blog
Book Your Appointment
Dental Records / X-Ray Release Authorization
Patient Name
(Required)
Date of Birth
(Required)
MM slash DD slash YYYY
Authorization Notice:
I hereby authorize the release of my dental records, including all diagnostic X-rays, charting, and relevant dental information from my previous dental office to be sent to
The Dental Land Family Dental Clinic, NW Calgary, Alberta
. I understand that these records are being requested to assist in my ongoing dental care. This authorization is voluntary and will remain valid until the requested records have been released.
Previous Dental Office
Please provide the details of your previous dental office
Previous Dental Office Name
(Required)
Previous Dental Office Phone
(Required)
Previous Dental Office Email
Previous Dental Office Fax
Records To Be Sent To
🦷 The Dental Land Family Dental Clinic
NW Calgary, Alberta
Phone:
(587) 864-4300
Email:
info@thedentalland.com
Patient Signature
(Required)
Date of Signature
(Required)
MM slash DD slash YYYY
Is the patient a minor?
(Required)
No — Patient is an adult
Yes — Patient is a minor (under 18)
Parent / Guardian Section
Required only if the patient is under 18 years of age
Parent / Guardian Name
Parent / Guardian Signature
Parent / Guardian Date of Signature
MM slash DD slash YYYY
