Patient Release

Dr. Hania and her team is dedicated to ensuring that you receive the best care and attention. If you wish to transfer your current X-rays and records to Dr. Hania, you may fill out the form below and forward it to us.

Patient Release Form

Patient Name(Required)
MM slash DD slash YYYY
Please separate names using a comma
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY
MM slash DD slash YYYY

Kindly provide bws within the last two years and panorex within the last five years only.

Thank you.

 

Contact Us

Dr. Hania and her team is dedicated to ensuring that you receive the best care and attention. Please use the form below to reach out to us.

(613) 680 2888

613-680-2890

1390 Clyde Ave. Unit 102, Ottawa, ON K2G 3H9

info@clydedentalcentre.ca

Opening Hours:

Mon-Thurs : 8:00 am - 4:30 pm

Fri-Sun : Closed