DENTAL RECORDS / X-RAY RELEASE FORM
I give authorization to release my dental x-rays and dental records to
the office of Imperial Dental Associates for my continued treatment.
Imperial Dental Associates
15 Imperial Avenue
Westport, CT 06880
By clicking the accept button below, I agree that the signature I have drawn above will be the electronic representation of my signature for all purposes when I use them on online documents and forms - just the same as a pen-and-paper signature.