Make an Appointment with Chanhassen Family Dentistry
Chanhassen Family Dentistry
X-ray Release Form


  • 8116 Mallory Court
    Chanhassen, MN 55317
    952-443-3368

  • AUTHORIZATION RELEASE FORM




    All patients requesting x-rays must have the following release completed and signed.

    By signing below, I am authorizing the release of my x-rays.
  • Date Format: MM slash DD slash YYYY
  • Please email x-rays to office@chandent.com
  • Date Format: MM slash DD slash YYYY
  • (If signed by someone other than the patient)