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Authorization for Release of Dental Information


hereby authorize

to release any and all dental records and radiographs relative to my care to:

Family Dentistry of Caledonia
9021 N. Rodgers Ct
Caledonia, MI 49316
Additional family members for whom you are requesting release of information

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.