Record Release Request First Name *Last Name *Authorize the release of all dental records of my children/family and ask that you may forward them to Fallowfield Dental. Fallowfield Dental 6 - 3350 Fallowfield Rd.Phone: 613.440.9000 Fax: 613.440.9003 Email: info@fallowfielddental.com Please include the following: Any Radiographs you have on file for the patient(s Date of last Complete Exam and Date of last Recall Exam.Date of last Complete Exam *Date of last Recall Exam *Date of last Hygiene Appointment *Most recent set periodontal probing/PSRPatient Name *SignatureStart signing your signature here *Sign hereYour browser does not support e-Signature field.Date *Submit
