Our services - A1Care testimonials - A1Care

“State of the art equipment; beautiful office”

contact us - A1Care

9560 SW 107th Ave

Suite 206, Miami, FL 33176
Ph: (305) 274-2110
Fax: (305) 274-2109
New Patient Questionnaire >>
Email us!


X-Ray Request Form - A1Care

It would be very helpful if we could obtain any x-rays taken at your previous dental office. Most offices require a release form; you may download this form or call our office to provide you with such form, and you may fax it or mail to your previous dental office and they will forward any x-rays to us.

Thank you for your cooperation.

Authorization and Request for Previous Dental Records and Radiographs
Previous Dentist:
Address:
City, State, Zip:

Please forward any previous x-rays and/or records as soon as possible to:

Judy Mejido DMD PA

9560 SW 107th Ave, Suite 206
Miami, FL 33176
Ph: (305) 274-2110
Fax: (305) 274-2109
Email: a1care.dentistry@gmail.com

Thank you.

Signature:
Name:
Address:
City, State, Zip:
Phone Number:
Additional Comments/Notes :