RICHARD WILSON, DMD PC DENTAL ARTS & SCIENCES RICHARD S. WILSON, JR., D.M.D., F.A.G.D. SHU-ZHEN KUANG, D.M.D. Date Dear ___________________________ I hereby authorize and request you to release the complete medical and dental records in your possession, concerning my treatment while under your care to: Richard Wilson DMD, PC 2401 Pennsylvania Avenue, Ste. 1A8 Philadelphia, PA 19130 If radiographs are digital please email them to records@smilephiladelphian.com Signed__________________________________________ Date________________ Print Name _____________________________________
RICHARD WILSON, DMD PC DENTAL ARTS & SCIENCES RICHARD S. WILSON, JR., D.M.D., F.A.G.D. SHU-ZHEN KUANG, D.M.D. Date Dear ___________________________ I hereby authorize and request you to release the complete medical and dental records in your possession, concerning my treatment while under your care to: Richard Wilson DMD, PC 2401 Pennsylvania Avenue, Ste. 1A8 Philadelphia, PA 19130 If radiographs are digital please email them to records@smilephiladelphian.com Signed__________________________________________ Date________________ Print Name _____________________________________
Release-Form-Incoming-2017.docx