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Release From Our Office
A request has been made to transfer your records to another office. Please print the name of the patient whose records you would like transferred.
Patient's First Name
Patient's Last Name
Patient's Middle Initial
Date Of Birth
Please forward X-rays To:
New Office Phone Number:
New Office Email if Applicable:
Patient/Legal Guardian Signature
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Date
We will miss you and wish you the best in the future!
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