Bellingham Bay Dental

Dr. Grant McClendon DMD
1118 Finnegan Way, Suit 101, Bellingham, WA 98225
(360) 676-0760 / Fax (360) 734-7198
, hereby authorize Bellingham Bay Dental to release information in my dental records to:

Information to be release: Radiographs and any other information in my dental records that would be useful for future treatment. Bellingham Bay Dental is hereby released from all legal responsibility or liability for the release of the above mentioned disclosure of information.

I understand that I have the right to withdraw this authorization at any time and that such revocation must be in writing. Further, I understand that this authorization, without prior revocation, will expire 90 days from the date of signature.

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