CANSLER DENTAL : 770-475-9095
12220 Birmingham Hwy Bldg 100, Milton, GA 30004
Record Request - Release Form
Please release records to my new dental office.
Patient Name:
*
First Name
Last Name
Date of Birth:
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Month
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Day
Year
Date
Patient Name:
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
Date
Patient Name:
First Name
Last Name
Date of Birth:
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Month
-
Day
Year
Date
New Dental Office:
*
New Dental Office Phone Number
*
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Area Code
Phone Number
New Dental Office E-mail
*
*
I give authorization for these records to be released from Cansler Dental.
Signature/Relation to Patient
*
Clear
Date Signed
*
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Month
-
Day
Year
Date
Submit
Should be Empty: