Please correct the errors described below.

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.

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