Patient Release of Dental Records Patient Release of Dental Records Your Name (required) Your Email (required) I authorize my records to be released and all images/ x-rays or pertinent records be emailed/sent securely to Sapphire Family Dental. Please email them to info@sapphirefamilydental.com Previous Dental Office name Previous office email address Previous-dental-office-phone Date of x-rays: Type of images Date of panoramic FMX (full mouth) Date of Bitewing Images: Signature:
