New Patient Release of Records

Please correct the errors described below.

Records Release Request

I hereby authorize the release of my dental record or copies of such and request that they be transferred

River Forest Dental Studio
344 Lathrop Ave, River Forest, IL, 60305
Phone: (708) 366-6760
Fax: (708) 366-6762
Email: office@riverforestdental.com

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X-Rays Requested:

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