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

I, (print name of patient or guardian)

hereby authorize the doctor and staff of Greenview Cosmetic and Family Dentistry to release records of knowledge concerning (print name of patient)

dental health to:

Dr. Name/Dental Practice:

Street Address:

City, Zip Code:

Telephone number/email:

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

Signature of Patient/Guardian

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