Dr
REQUEST FOR RELEASE OF DENTAL INFORMATION
Date:_________________________________________
Doctor/Facility Name:____________________________
Address:_______________________________________
_______________________________________
_______________________________________
Patient Name:___________________________________DOB____________
Patient Name:___________________________________DOB____________
Patient Name:___________________________________DOB____________
Patient Name:___________________________________DOB____________
I hereby grant permission for the release of dental records and x-rays to Dr. Fethiye Ersan from the above address for the patients listed above. Please send x-rays via email to: appleblossomdental@
________________________________________ ________________________
Signature of Patient or Parent/Guardian Date
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