Isabella Piedra, DDS
9469 Haven Avenue, Suite 100, Rancho Cucamonga, CA
AUTHORIZATON TO RELEASE PATIENT RECORDS
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
Thank you for your cooperation.
Use your mouse cursor or the tip of your finger to sign below