X-Ray Request and Release Form Authorize the transfer of your dental records and x-rays to Cumberland Dental.Patient InformationDate*Patient Name*Date of Birth*AuthorizationI hereby authorize the release of my dental records and x-rays fromPrevious Dental Office*and request they be transferred to:CUMBERLAND DENTAL #60 -1519 8th Street East Saskatoon, SK, S7H 0T2 306-952-3003Please forward requested x-rays to info@cumberland-dental.comSignatureSignature of Patient*ClearSubmit✓Thank you!Your form has been submitted successfully. The office will receive your information shortly.Back to Home
