Request for Release of Records - Cloudinary
Office Name: _______________________________________________
Office Address: _____________________________________________
Office City/State/Zip: _________________________________________
Office Phone Number: ________________________________________
Request for Release of Records
Date: ______________________
I hereby authorize the release of my dental records or copies of such and request that they are
transferred to:
To (Doctor or Hospital):
Address:
City:
State:
Zip:
Patient Name:
Date of Records:
Patient¡¯s Signature:
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