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Alison K Jackson, DDS - Authorization to Release Patient Records
This form provides authorization and consent for Dr. Alison Jackson to release your child's dental record to the specified party listed below.
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* Indicates required question
Patient's Full Name:
*
Your answer
Patient's birthday:
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MM
/
DD
/
YYYY
Parent/Guardian's Full Name:
*
Your answer
Please mark here:
*
I authorize Dr. Alison K. Jackson to release all records concerning findings and treatment of the child named above to the party listed below.
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