• I hereby authorize (Former Dentist's Name or Dental Office to provide MidTown Smiles Dental Care with copies of my dental records with respect to any dental care and treatment that I have received. I understand that the specific type of information to be disclosed includes a detailed report of examinations, treatment provided, x-rays and all other records which pertain to me. I understand that the information obtained as a result of this consent may be used after the cancellation date.
  • Please email all records MidTown Smiles Dental Care info@midtown-smiles.com
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