SOLACE DENTAL CARE

Dr. Steve Petryk & Associates

823, 10 Ave S.W

Calgary, Alberta T2R 0B4

Telephone: (403) 266-6868

Facsimile: (403) 262-2612

Release of X-ray Form

Patient Name: __________________________________________

I authorize Solace Dental Care to release my x-rays to the following DENTIST:

Name: _________________________________________________

Address: _______________________________________________

City: __________________Province: __________ PC.: __________

Telephone: (____) _______________.

_______________________________________________________

Signature

Date: _____/_____/_____.