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Records Request Form
Patient Last Name
Patient First Name
Date Of Birth
I authorize
(current healthcare provider) to release my child's dental record(s) to Sierk Children's Dentistry; for their upcoming dental examination.
Please forward most recent xrays to:
FrontDesk@SierkPD.com
.
If we can assist further, please contact us at 303.865.4066
Thank You
Jonathan D. Sierk, DDS
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