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Patient authorization to release confidential information

Smile Pro Studio

1701 E. Woodfield RD # 510,
Schaumburg, IL 60173
(847) 850-0254

Patient Details( * mandatory to fill )
( * mandatory to fill )

I, authorize to disclose and provide copies of any and all clinical treatment, records, and information concerning my care (or child's if patient is under 18 years of age) which is in the clinic's possession to be sent to the following dentist or entity:

These records include but are not limited to: Patient information, medical and dental history, examination records, radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and other related materials.

I expressly release from liability the above-named person or entity from any and all liability arising from compliance with this request and disclosure of requested information.

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