www.centreplacedental.com - Release of Records Form

I (patient or guardian) hereby request and authorize (dentist or dental practice) to provide copies of any current films and necessary records or notes concerning my care to
CENTRE PLACE DENTAL.
Name
Date of Birth
Date of Birth
Name
Date of Birth
Name
Date of Birth
Name
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All records can be emailed to Centre Place Dental at secure@centreplacedental.com. Thanks!
Signature*
Name*

First NameLast Name
Date*

MonthDayYear
Date
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