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Patient Dental Records Release Form

Patient Dental Records Release Form

Use a printable dental records release form 0 template to make your document workflow more streamlined.

City/State/Zip Office Phone I understand that my express consent is required to release any healthcare information relating to my dental care. I hereby consent to the release of the above requested information only. Signature of patient or patient s authorized representative Date signed Relationship or status if signed by anyone other than patient parent legal guardian etc*....
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