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Release of Records
3504 Oakwood Mall Drive
Eau Claire, WI 54701
Phone: (715)895-6531 Fax: (715)895-6535
info@bullisponddental.com
AUTHORIZATION FOR RELEASE OF DENTAL RECORDS
I hereby request the disclosure of Information from my dental records on file with your office.
First Name
Last Name
Date Of Birth
Previous Dental Office/ Transferring Office:
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