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Records Release Request

I,

(name) hereby authorize the release of my dental records:

Current Digital Xrays

Please send my xrays via. Email to the dental office info given below:

Dental office

Address

Telephone

Email

Patient Name (print)

Patient phone number

Signature

Date

We require 30 working days from the time we receive this document to process your request.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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