Authorization of Release of Dental Records and X-Rays TO Calcagno DDS

    I, (print name of patient or guardian)

    hereby authorize the doctor and staff of (dental practice name)

    (street address)
    (city, zip code)
    (telephone number/email)

    to release records of knowledge concerning (print name of patient)

    dental health to Calcagno Cosmetic and Family Dentistry.
    Signature of Patient/Guardian

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