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I authorize my records to be released and all images/ x-rays or pertinent records be emailed/sent securely to Robert Derr and Amy Chi Family Dentistry. Please email them to info@DentistEP.com Previous Dental Office name Previous office email address Previous-dental-office-phone Date of x-rays: Type of images Date of panoramic FMX (full mouth) Date of Bitewing Images: Signature:
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