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Request for Release of Dental Records
First Name
Last Name
Date Of Birth
Phone Number
Email Address
Previous Dental Office:
Reason for leaving
Office Phone Number
Office Email Address
I hereby authorize the transfer of my dental records, including all current radiographs to be sent to:
River Bluff Dental
10851 Rhode Island Ave S
Bloomington MN 55438
(952) 884-5361
Info@RiverBluffDental.com
Patient/Legal Guardian Signature
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