• Request for Release of Records

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  • hereby request and give my permission to Dr. Robert Olson to provide

  • any and all information which he/she may request with respect to the orthodontic care of 

  • Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, x-rays, models and copies of all dental records and medical records.

    I agree to pay the cost of duplicating any records (N/A).  A photocopy of this release will be as effective and valid as the original.

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  • Social Security # N/A

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  • (Parent, Legal Guardian or Custodian of the Patient, if appropriate)

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  • ©American Association of Orthodontists 2019 Reviewed 2018

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