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Dental Record Release Form

Patient Information

I hereby request that my dental records be released to:

By my signature I authorize the release of my dental records.

Please use your finger or curser to sign your name.

Grove Park Dental Group needs the contact information you provide to us to contact you about our products and services. You may unsubscribe from these communications at any time. For information on how to unsubscribe, as well as our privacy practices and commitment to protecting your privacy, please review our Privacy Policy.

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