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Patient Information Release Form

I authorize

Printed Dentist Name

to release my dental/medical information to:

CARRIE RANDOLPH DDS INC

office@toothcarriedds.com

Expires in 6 months from date of signature unless otherwise noted:

No Expiration Date

Patient's Name

Date of Birth

Patient/Parent Signature

Date

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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