Records Release Authorization

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Name

Address

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Fax Number

Email

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Ray Dental Group110 Minnesota StRapid CitySD57701USAPhone605.343.2842Fax605.343.2829Emailfrontdesk2@raydental.com

All patient(s) listed below to be transferred:

Patient Name

Date of Birth

Patient Name

Date of Birth

Patient Name

Date of Birth

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