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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