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Release of Records
I hereby authorized release of records to:
Sunrise Dental Bellevue
Phone #425-450-9500
Fax #425-450-5008
Email Address:
Bellevue@sunrisedental.com
1200 112th AVe NE Suite C222 Bellevue Wa 98004
From the following office:
Name of Office:
Email Address:
Fax Number:
Phone Number:
Office Address:
Please release the following records:
Entire Dental Records
Any x-rays, Panoramic or FMX
Perio chart
Chart notes
Treatment plans
Patient First Name
Patient Last Name
Patient Date Of Birth
Patient/Legal Guardian Signature
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