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Records Request
Please send the items below in JPEG format, if available:
Full mouth series of x-rays within 5 years
Panoramic x-ray within 3 years
Bitewing x-rays within 1 year
Perio charting within 3 years
Other relevant patient or treatment information
Mailing Address:
Manlius Dental Group
102 West Seneca Street, STE 100
Manlius, NY 13104
Phone:
(315) 682-8400
Fax:
(315) 692-2800
Email:
manliusdentalgroup@gmail.com
I authorize the release of dental records relevant to dental treatment, or copies of such to the above address.
Patient First Name
Patient Last Name
Patient Date Of Birth
Patient, Parent or Legal Guardian Signature
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Date
Previous Dentist Name:
Previous Dentist Phone:
Previous Dentist Fax or Email Address, if known.
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