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2014-06-07 2147

 

 

 

RECORD TRANSFER

 

 

Dear Dr. ________________                                         

We are currently treating ________________________, a former patient of your practice. This correspondence authorizes your office to release all dental records to the above noted dental office. Thank you for your timely response.

    

      Sincerely,

 

 Dr. Joe Miskin, D.D.S

_________________________                                                                  ________________

        Patient Signature                                                                                       Date