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Authorization for Release of Dental Records and X-rays
I, (guardian)
First Name
Last Name
Date Of Birth
hereby authorize the doctors and staff of Temple Family Dentistry to release (patient name)
Patient Name
records, x-rays or knowledge concerning my dental health to (fill all that applies including office name and phone number):
Office Name:
Practice Telephone Number:
Email Address:
Street Address:
City, Zip Code:
Please select the following requested. I specifically request that you release copies of:
Signed:
Patient/Legal Guardian Signature
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Signature Pad
Date
Printed Name (patient of guardian)
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