X-Ray Authorization Form
Authorization To Release X-Rays

 

I, , authorize Tender Care Dentistry to email my child ’s, x-rays directly to another dental office for any of the following reasons:

In the event Tender Care should refer my child to another dental office or specialist for a consultation and/or treatment.

In the event I choose to transfer my child to another dental office for a consultation and/or treatment.

 

Contact Us
Charlotte Hall, MD Pediatric Dentist
Tender Care Dentistry
29795 Three Notch Road
Charlotte Hall, MD 20622
(301) 298-2622
(301) 290-5633 fax
Charlotte Hall Pediatric Dentist Call For Pricing