X-RAY REQUEST FORM From:
St. Michael Dental Center
399 Central Ave E.
PO Box 279
St. Michael, MN 55376
Phone: 763-497-2040
Fax: 763-497-4418
TO: _______________________________
_______________________________
_______________________________
_______________________________
(Please include phone number)
To Whom It May Concern:
The person(s) listed below have recently become a patient at our office and has asked that
we request his/her previous dental records. By signing below, the patient is authorizing these
records to be released to us. Please forward any current x-rays to our office and dates of
previous x-rays, cleaning and exam. Signatures needed below next to name for anyone over
18.
_________________________________________________________________________
_________________________________________________________________________
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Thank you in advance for your prompt attention.
Sincerely,
Dirk Posthumus, DDS
John Biorn, DDS
Agnes Wawra, DDS
__________________________________________________________(Signature)
__________________________________________________________(Signature)