Patient Radiograph Release Consent Please enable JavaScript in your browser to complete this form.Please enable JavaScript in your browser to complete this form.Patient Radiograph Release Consent: (to be completed by patient) Previous Dental Office:Phone:Patient Name *Family Members:Signature * Clear Signature Date / TimeREQUEST FOR DENTAL RECORDS: (to be completed by Bell Dental staff) Name Checkboxes / Please provide copies of the following records:Bitewing radiographsPanorex radiographPeriapical radiographsCheckboxesInclude records for myself onlyInclude records for family membersSubmit