IMAGE REQUEST appointment date. - Amazon Web …...2018/12/08 · IMAGE REQUEST In order to be...
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Date: __________________________________ Referred by: Dr. ____________________________- Address: __________________________________________________________________ Phone Number: __________________________- Fax Number: __________________________- Email: _______________________________________________________ Patient Name: _________________________________________ Phone Number: __________________________- Email: _______________________________________________________ IMAGE REQUEST In order to be fully prepared for this appointment we request that you e-mail most recent images to our office at least two days prior to appointment date. Please note we unfortunately are no longer able to accept hard-copy images. Please send digital images, if available, to: [email protected] Thank you and we look forward to working with you. Fairfield Orthodontics www.fairfieldortho.com Phone: 707-428-3200
Transcript of IMAGE REQUEST appointment date. - Amazon Web …...2018/12/08 · IMAGE REQUEST In order to be...
Date:__________________________________
Referredby:Dr.____________________________-Address:__________________________________________________________________PhoneNumber:__________________________-FaxNumber:__________________________-Email:_______________________________________________________PatientName:_________________________________________PhoneNumber:__________________________-Email:_______________________________________________________IMAGEREQUESTInordertobefullypreparedforthisappointmentwerequestthatyoue-mailmostrecentimagestoourofficeatleasttwodayspriortoappointmentdate.Pleasenoteweunfortunatelyarenolongerabletoaccepthard-copyimages.Pleasesenddigitalimages,ifavailable,to:records@fairfieldortho.comThankyouandwelookforwardtoworkingwithyou.FairfieldOrthodonticswww.fairfieldortho.comPhone:707-428-3200
