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MICHAEL J. GEREMINO, D.D.S47 Brookfield PlacePleasantville, New York 10570(914) 769-0065(914) 769-3214 (Fax)Email: drmgeremino@**REQUEST OF X-RAY/RECORDS RELEASE FORM**I, _____________________________ hereby authorize and request the release of my dental[Please Print] records and of X-rays taken of me to:□ Me (the patient)Address:____________________________________________________________________City/State/Zip________________________________________Phone:__________________□ Name of Relative/Other______________________________________________________Address:____________________________________________________________________City/State/Zip:________________________________________Phone:__________________□ Physician/Hospital__________________________________________________________Address:____________________________________________________________________City/State/Zip:________________________________________Phone:__________________Patient Signature:____________________________________Date:______________________________________________ ................
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