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REQUEST TO RELEASE/TRANSFER DENTAL RECORDS

By signing this form, I hereby request the release and/or transfer of my dental records and radiographs.

William I. Kincaid, III, DDS, PLLC
James T. Purvis, DDS
Donovan Godwin, DDS
635 McCarthy Blvd.
New Bern NC, 28562
Phone (252)636-0011         Fax (252)288-5715
Email to: scheduling@kincaidandpurvis.com

Signature Pad

Please list any additional patients covered by this release:
Done