Isabella Piedra, DDS

9469 Haven Avenue, Suite 100, Rancho Cucamonga, CA

909.483.6851

AUTHORIZATON TO RELEASE PATIENT RECORDS

I,
hereby authorize and request the release of the records and x-rays concerning any and all treatment rendered. Please forward within five working days.
Requesting records for:
Records to be released to:
Children’s Dentistry of Rancho Cucamonga
9469 Haven Avenue, Suite #100
Rancho Cucamonga, CA 91730
Office@ranchokidsdentist.com
Thank you for your cooperation.

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