Record Release Form

S. Lee Falkenheiner, DDS, PLLC | 303 Carter Street Vidalia, LA 71373 | Phone: (318) 336-9688

Please correct the errors described below.

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

Email: Telephone: 318-336-9688 Fax: 318-336-9804

Your information will be encrypted.