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Records Request Authority Form
encounterbay
2022-05-24T15:14:22+00:00
Records Request Authority Form
Records Request Authority Form
Patient Name
Patient of
Doctor name
DOB:
here by authorize and direct release of my dental records (including radiographs) to Dr.__________of Encounter Bay Dental.
Signature
Sign Here
Date
I have an appointment at Encounter Bay Dental on
Submit Form
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