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

    I, (print name of patient or guardian)

    hereby authorize the doctor and staff of Calcagno Cosmetic and Family Dentistry to release records of knowledge concerning (print name of patient)

    dental health to:

    Dr. Name/Dental Practice:

    Street Address:

    City, Zip Code:

    Telephone number/email:

    Signature of Patient/Guardian

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