Dental Records Request

Patient's Name

Date

From

Address

To: Dr.

Dear Dr.

Date of Birth

,request that you send a copy of my dental records and radiographs to,

DWIGHT J. ROEPCKE DMD
275 North Pine St. Ste.A
Langhorne, PA 19047
215-750-1125

I thank you for your prompt attention to this matter.
Sincerely,

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