• Patient Records Release Form

    Androscoggin Dental Care
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    Previous Dental Office:* may Release Records to:

    Name of Practice: Androscoggin Dental Care
    Mailing Address: 7 Main St., Topsham ME. 04086

    Email Address: adc@beautifulsmile.com
    Phone: (207) 729-3911
    Fax: Fax: (207) 204-3427

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    Androscoggin Dental Care may Release Records to:

    Name of New Dental Office:*
    Mailing Address:
    Email Address:*
    Phone:
    Fax:

  • The records that will be included, but are not limited to: personal patient information, medical and dental histories, examination records, and radiographs, clinical photographs, treatment plans, treatment records, referral and consultation recommendations and reports, diagnostic models, and other related materials.


    I expressly release from liability the above names person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.

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