Request for Dental Information
You hearby request the release of copies of your dental radiographs and the date of your last check-up and any pertinent information regarding your dental and general health to the attention of Dr. Michael Melnychuk's office.
Personal Information
Name:
Address:
City:
Province:
Postal Code: *No dashes or spaces
Phone Number: *Require area code with no dashes or spaces
 
Previous Dentist
Name
Address
City
Province
Postal Code *No dashes or spaces
Phone *Require area code with no dashes or spaces
Fax *Require area code with no dashes or spaces
 
Confirmation
I hereby confirm that all of the information contained in this form is correct to the best of my knowledge
 
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