Record Release Form

Please correct the errors described below.

Kurt E. Peterson, DDS 1604 W. Riverside Ave Spokane, WA 99201 ph (509) 747-2183 fax (509) 747-3990

Please include current bitewings, any FMX or PANO taken within the last 5 years, probe readings and dates of 4341, if any. All records can be faxed to the number above or emailed to insurance@petersondental.com.

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.

Thank You

1604 W. Riverside Avenue • Spokane, WA 99201 www.petersondental.com • kurt@petersondental.com (509) 747-2183 ph (509) 747-3990 fax

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