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Patient's Full Name

Send Files and Records to:

Receiving Dental Practice Name

Receiving Dentist Name

Address (Street, City, State, ZIP)

Phone Number

I hereby authorize the release and delivery of the above named patient's records and files, copies of the most recent dental x-rays, and a summary of the most current dental findings.

I hereby release my current dentist and dental practice from any liability related to disclosure of confidental or privileged information to the receiving dentist and dental practice named above.

Signature of Patient, Parent (minor child patient) or Guardian

Today's Date

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