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
We have been asked to transfer your records to another office.
Please print the names of the patients whose records you would like copied and transferred.
_____________________________ ___________________________
_____________________________ ___________________________
_____________________________ ___________________________
Please circle option A or B.
A. Please send one year’s of my X-Rays including photocopied print & duplicate x-rays at no
charge.
B. Complete dental records, to be paid C.O.D. This option involves much more time and therefore
you will be billed for the time & materials. MN State Statute recommends $10.00 plus $ .90 per
page for photocopied pages, and $10.00 plus a fee per page for x-rays. Our fee per page for
copied x-rays is $3.00. I understand Option B will cost at least $20.00 per person.
Signature (or parent if under 18) _____________________________(Date)_________________
Signature (or parent if under 18)_____________________________ (Date)__________________
Please forward x-rays to:
_____________________________
_____________________________
_____________________________
_____________________________
(Please include phone number)
To help us serve our patients better-please indicate why:
__ Hours of operation __ Family scheduling conflicts
__ Moving out of area __ Billing problem
__ Change of insurance __ Other (please specify)__________
We will miss you and wish you the best in the future.
St. Michael Dental Center