X-Ray Submission from Other Offices (Dental)

Please use this form to share your records so that we can provide the best possible care for our mutual patient. You can use the following numbers if you need to reach us by phone:

South Valley Dental Clinic: 505-873-7423

Los Lunas Dental Clinic: 505-224-8740

Edgewood Dental Clinic: 505-224-8718
Patient's Full Name*

First NameLast Name
Patient's Date of Birth*

MonthDayYear
Date
Types of X-rays*

Full Mouth SeriesBitewing (vertical or horizontal)PanoramicPeriapicalExtraoral or Intraoral Digital ImageOther
Please submit the X-rays, images and / or other files here (multiple files can be attached):*

Cancelof
Date(s) the images were taken: *
Name of person submitting images:*
Your best contact phone number (in case we have questions)*
Dental office where images were taken:*
Comments
Should be Empty: