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
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