Authorization of Release of Dental Records and X-Rays TO Greenview Dentistry

I, (print name of patient or guardian)

hereby authorize the doctor and staff of (dental practice name)

(street address)
(city, zip code)
(telephone number/email)

to release records of knowledge concerning (print name of patient)

dental health to Greenview Cosmetic and Family Dentistry.

Types of Records And Dates Of Service That Are Being Requested:

Signature of Patient/Guardian

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