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Dental Record Release Form

Patient Information

First Name

Phone

Date of Birth

Last Name

Email Address

Last 4 digits of your Social Security

Street Address

City

Postal / Zip code

Region/State/Province

I hereby request that my dental records be released to:

Attention

Street Address

City

Postal / Zip code

Region/State/Province

Please let us know why you are changing dentist?

Please explain

By my signature I authorize the release of my dental records.

Please use your finger or curser to sign your name.

Your Signature

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