Record Release To Our Office
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Patient Name: *
Guardian Name (if patient is a minor): 
Mailing Address: *
Date of Birth: *
Phone Number: *
Previous Dentist Name: *
Previous Dentist Phone Number:
Previous Dentist Fax or E-mail:
I authorize the release of dental records & medical records relevant to dental treatment, or copies of such, and request that they be transferred to:
Parkview Dental
1200 Centre Park Drive Suite 100, Asheville, NC 28805
E-Mail address: office@parkviewavl.com
Phone number: (828) 252-3591

(Please type full name as your legally binding signature) 
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