• Radiograph and Records Request

    Please complete this form only to request records from a previous dental office.
  • Print blank form to fill by hand (Click Here)

  • Dear Doctor,


    Please accept this document as my formal request to have my most recent radiograph and dental records forwarded to the practice of Dr. John L. Aurelia and Dr. Dina Khoury at the following location:

    John L. Aurelia, D.D.S., PLLC,
    804 North Main Street, Suite 201-A,
    Rochester, Michigan 48307
    Email: frontdesk@aureliadds.com

    Thank you for your assistance in this matter.

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