Ready to join our long list of happy patients?

I, {Name (First):3.3} {Name (Last):3.6} (D.O.B.: {Date of Birth:12}), hereby authorize the release of my dental records to:

Chapel Hill Dental
3400 ch. Innes Rd., Orléans, ON K1W 0G1
Tel.: 613.424.4241 Fax: 613.424.8887
Email: smile@chapelhilldental.ca

Please forward all recent x-rays by email to Chapel Hill Dental at your earliest opportunity, together with the following information to assist them going forward:

Date of last COE
Date of last Recall Exam
Date of last Bite Wings
Date of last Panoramic Image

Thank you for your cooperation.