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Records Release
Patient First Name
Patient Last Name
Patient Date Of Birth
Additional Patient Names & DOB's within the same family:
By signing below, I am authorizing the release of dental records relevant to dental treatment, or copies of such to the below address.
All patient records are transmitted through a secure, HIPAA-compliant encrypted email system.
Dentist Name:
Dentist Phone:
Dentist Email Address:
Patient, Parent or Legal Guardian Signature
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