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RECORDS RELEASE REQUESTDoctors Name: Address: Phone Number: Fax Number: I authorize the release of my dental records to: Peter L. Thompson, D.D.S. 123 West 2nd St Portals, NM 88130 Phone: (575)3591011
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The doctor's name is Peter.
The hospital or clinic where Dr. Peter practices is required to file his name.
You can fill out Dr. Peter's name by providing his first and last name in the designated field.
The purpose of including Dr. Peter's name is to identify him as the attending physician or healthcare provider.
The information to be reported includes Dr. Peter's full name and credentials.
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