• Record Release

  • I, * , do hereby authorize the release of all dental records including x-rays from the office of * to be sent to *, at * in *.

  • I also release the above named offices from all legal responsibility that may arise
    from this authorization.

    If sending information to Mystic Dental Group, please send to:
    email: [email protected]
    fax: 860-572-1409

  • Clear
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