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Southern Family Dental Group
REQUEST FOR RECORDS
First Name
Last Name
Date Of Birth
Address
City
State
Zip Code
RELEASE MY DENTAL RECORDS FROM
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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