X-Ray Release Form

X-Ray Release Form


    To release health care information of the patient name above, to:

    Canterra Dental

    Suite 230 (2nd Floor)

    400 3rd Avenue SW

    Calgary, AB T2P 4H2

    Phone: (403) 237-6611

    Email: info@canterradental.ca

    This request and authorization apply to:

    • Copy of complete dental chart including periodontal measurements
    • Copy of dental x-rays (including Panoramic or FMS)

    I understand that my express consent is required to release any healthcare information relating to testing, diagnosis and treatment.

    Please forward all copies at your earliest convenience. I thank you in advance for your cooperation.

    Our Mission

    We are committed to maintaining a high standard of dentistry and to provide you with an efficient on-time experience. We believe in openly discussing and explaining your treatment options.

    Our goal is to work directly with you to enhance your smile and your overall oral health.

    Dr. Dennis Leung, DDS

    Dr. Dennis Leung | Dentist | Canterra Dental Centre | Downtown Calgary | General and Family Dentist