REQUEST OF RELEASE OF HEALTH INFORMATION

Please correct the errors described below.

Hereby grants permission to:

To release information related to my Dental/Health history, status, treatment and copies of my Dental/Health records, X-Rays and any test results to:

Dr. Anett John, DDS, LLC
5530 Wisconsin Avenue, Suite 1240
Chevy Chase, MD 20815
301-652-3317
drajohndds@gmail.com

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

(If a minor, a parent or guardian must sign)

Your information will be encrypted.

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