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AUTHORIZATION FOR RECORDS RELEASE

I give my permission to the staff of Delgado Dental Group to duplicate my x-rays and/or any necessary records and release them to the following location:

Name:

Address:

City:

State:

Zip:

I will / will not be returning to the Delgado Dental Group for future appointments.

Will

Will Not

Please print your name

Signature

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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