Release of Information Form

Release of Information Form v2

PATIENT AUTHORIZATION FOR RELEASE OF INFORMATION

Date:
I herby authorize the release of my Child(ren)s Information:

Or

Please forward to my home email.
Cancel all Future Appointments?

I understand that Dentistry for Children will provide one copy of these records at no charge. If for any reason more than one copy of x-rays is needed; there will be a duplication fee.



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DentistryforChildren&Adolescents

Dentistry for Children & Adolescents

  • Edina Office - 7373 France Ave. S., Suite 402, Edina, MN 55435 Phone: 952-831-4400
  • Burnsville Office - 14050 Nicollet Ave., Suite 100, Burnsville, MN 55337 Phone: 952-435-4102
  • Eden Prairie Office - 6385 Old Shady Oak Road, Suite 150, Eden Prairie , MN 55344 Phone: 952-932-0920

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