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Elevate Dental Release of Records Form
First Name
Last Name
Email
Date Of Birth
Release of Information
Please indicate your transfer status:
Release of Information
Doctor Name
Office Name
Phone
Email
Address
City
State
Zip Code
Form of Disclosure:
Reason for Disclosure:
If Other / Any Additional Comments
Are there any dependents UNDER 18 to release to the same office as noted above?
If yes, please list:
Consent
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Signature Pad
Date
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