Release of Records Consent
Fax: 360-841-7070 EMAIL: email@example.com
Date of Birth
Additional Family Members
Name of previous dental office
By checking this box and signing below, I authorize Dr. Brad Halleck's office to obtain my most current radiographs, periodontal chart, and necessary records from my previous dental office listed above.
Yes, I authorize my records to be transferred to TOWN DENTAL, the office of Brad Halleck, DDS via email to: firstname.lastname@example.org
Enter the message as it's shown
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