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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