INFORMED CONSENT TO RELEASE RECORDS

I hereby consent to and request the release of any and all dental records to Dr. Jeremy Ledger

Patient's Name: __________________________________		DOB_____________

Patient's Signature ____________________________________________________
(Parent, if minor) 

DATE: _________  

Please Send
Pan & FMX   Within 5 Years
Bitewings   Within 12  Months

You can Email:                              LedgerDentistryFrontDesk@GMail.com
              Or
Physically Mail:                           
3640  S. Suncoast Blvd                                                              
Homosassa, FL 34448

Please do not fax films as they are of no diagnostic quality.

Date: _________________________

I ________________________________ understand that Ledger Dentistry will submit this request for records on my behalf and that it is my responsibility to make sure that the films arrive prior to my appointment at Ledger Dentistry. 
In the case that the films do not arrive at Ledger Dentistry prior to my appointment, Ledger Dentistry will take the necessary films required by their office and I will be 100% financially responsible for the films. 
I understand that my insurance company has restrictions on what X-Rays they will pay for within certain time limits and that making sure my films arrive PRIOR to my appointment  will save me money.

_____________________________________		_____________________________________
                                                        Print  Patient Name                                                                                                                    Patient/Guardian Signature

Tips: 
- Call your previous Dental office and ask them to send the X-Rays.
- Call us to make sure your films are here at least 4 days before your appointment.
- If we still have not received your films, call your previous dentist until we receive them or go to their office and pick them up.

Name of your previous Dental Office: ____________________________________

City or location of that office: ___________________________________________       

Phone Number: ______________________      Fax number: ______________________