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TRANSFER OF MEDICAL RECORDS CONSENT FORM I, Patient Name of, Patient Address Date of Birth Hereby Authorize, Name of previous Dentist Name of previous Practice Please release electronic or hard copy

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Who needs 20150514 - gd:

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Individuals who are required to report certain information or provide specific details related to a particular event, activity, or program may need to fill out form 20150514 - gd.

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