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RECORDS RELEASE REQUEST I hereby authorize release of dental records for my child, Please PRINT child's name Dental records requested are: Bite wing rays Other intramural rays Panoramic rays Chart
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Provide your personal information such as your full name, date of birth, and contact details as requested.
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Who needs i hereby authorize release?

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Individuals who wish to grant permission for their personal information to be released to a specific person or entity.
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