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Release of Information
Patient's First Name
Patient's Last Name
Patient's Date Of Birth
Parent's Email
Phone
Address
City
State
Zip Code
Release of Information
Release of Information
Records may be released to:
Dentist's Name
Office Name
Phone
Email
Address
City
State
Zip Code
Form of Disclosure:
Reason for Disclosure:
If Other:
Parent/Legal Guardian Consent
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Date
Relationship to Patient:
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