I authorize the release of dental and medical records and x-rays relevant to dental treatment, or copies thereof, and request that they be transferred to:
Elegant Smiles of Sea Girt, LLC
Dr. William S. Steiner, D.M.D
2130 Highway 35, Suite 211
Sea Girt, NJ 08750
Phone (732) 974-9494
Fax (732) 974-8601
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.
Add new row
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2022 Hush Communications Canada Inc.