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Release of Records
Release of Information
Dental Office Name
Email
Address
City
State
Zip Code
Phone
Please list name(s) and date of birth for ALL patient whose records need to be transferred:
Patient's First Name
Patient's Last Name
Date Of Birth
Patient's First Name
Patient's Last Name
Date Of Birth
Patient's First Name
Patient's Last Name
Date Of Birth
Patient's First Name
Patient's Last Name
Date Of Birth
Patient's First Name
Patient's Last Name
Date Of Birth
Patient's First Name
Patient's Last Name
Date Of Birth
Patient's First Name
Patient's Last Name
Date Of Birth
Patient/ Parent Signature
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Date
Reason for Transfer:
If Other, please list
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