By submitting this form, I, the undersigned patient (or legal guardian of the patient), hereby authorize:

Release of Information: My previous dental office, as specified in this form, to release copies of my dental x-rays (radiographs) and any associated relevant diagnostic images to London Heritage Dental.

Purpose of Release: I understand that these x-rays are being requested by London Heritage Dental for the purpose of establishing a comprehensive dental record, facilitating continuity of care, and aiding in diagnosis and treatment planning for my dental health needs.

Recipient of Information: The released x-rays will be sent directly to London Heritage Dental via the email address info@londonheritagedental.ca, or they may be uploaded by me directly through the file upload feature on this form, or sent via other secure electronic means as agreed upon by London Heritage Dental and the releasing office.

Privacy and Confidentiality: I acknowledge that London Heritage Dental is committed to protecting my personal health information in accordance with applicable provincial and federal privacy legislation, including but not limited to Alberta's Health Information Act. My x-rays will be stored securely and used solely for the purposes outlined herein, or as otherwise permitted or required by law.

Voluntary Consent: I understand that this authorization is voluntary and that I have the right to refuse to sign this authorization. My refusal will not affect my right to receive dental care at London Heritage Dental, but it may impact the completeness of my dental record and potentially affect treatment planning.

Right to Revoke: I understand that I have the right to revoke this authorization at any time by providing written notice to London Heritage Dental. However, revocation will not apply to information that has already been released in reliance on this authorization.

Accuracy of Information: I confirm that the information provided in this X-Ray Release Authorization form is accurate and complete to the best of my knowledge.

Authorization for Family Members (If Applicable): If I have listed additional family members on this form, I confirm that I am the legal guardian or have obtained the necessary consent from each listed family member to authorize the release of their dental x-rays under the same terms and conditions outlined in this agreement.