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Rug 1z 2008 2:53PM �ustin Dental 6�17773463 p.l <br />� <br />Dr. $rad Austin <br />Austin Dental Associ�ates <br />1�60 Beam Avenue <br />Suite A <br />Maplewaad, MN 55109 <br />RELEASE QF DEIVTAL �tECORDS <br />I� �r °� «b � , request to have the dental records of <br />those listed below forwarded to; <br />G kia..`� i�c.v� ( <br />v0 , ula��r. <br />5•,�A <br />V.� o b ,.I 5512 <br />Name of patient (s): nr� Ll o d Birth Date: 9� 1 q'} l <br />Birth I3ate; ` <br />Birth Date� <br />Birth Date: <br />� / . ' b 8' <br />Sign e f person/gu dian whose records are to be released D <br />Reason for <br />Transfer; �!wq t. _ o� �r �S ura✓1 <br />� <br />� <br />