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Patient
Name: | _________________________________ | Patient ID: | _________________________________ |
Phone: | _________________________________ | Email: | _________________________________ |
Address: | _________________________________ |
Transfer From
Original Dentist: | _________________________________ | Clinic: | _________________________________ |
Fax: | _________________________________ | Email: | _________________________________ |
Phone 1: | _________________________________ | Phone 2: | _________________________________ |
Address: | _________________________________ |
Transfer To
New Recipient: | _________________________________ | Clinic: | _________________________________ |
Fax: | _________________________________ | Email: | _________________________________ |
Phone 1: | _________________________________ | Phone 2: | _________________________________ |
Address: | _________________________________ |
Authorized Information to Disclose