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REQUEST FOR RECORDS
First Name
Last Name
Date Of Birth
Address
City
State
Zip Code
OFFICE NAME
OFFICE PHONE
OFFICE EMAIL
Please release a copy of my dental records, including but not limited to: progress notes, x-ray films and diagnostic records.
By my signature, I authorize the release of my dental records to Southern Family Dental Group. Please forward all records to
info@southernfamilydentalgroup.com
.
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