Records Release Request - Columbia Dentistry for Children

[Pages:1]Robert D. Coyle, DDS

Gregory L. Stine, DDS

Maice A. Scott, DDS

1000 W. Nifong, Bldg. 6, Ste. 130

Columbia, MO 65203

573-874-1990

Fax 573-874-1923

info@

Records Release Request

Date:

________________________

To:

________________________

(Name of Dentist or Clinic you are request records from)

Address: ________________________

________________________

________________________

I hereby authorize the release of dental records and/or radiographs for:

_______________________

(Patient Name)

________________________

(Date of Birth)

________________________

(Parent Signature)

________________________

(Date)

Records release request.doc Revised 10/11/11

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