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PATIENT REQUEST FOR TRANSFER OF RECORDS

By submitting this form I request and give permission to transfer any and all dental records to the below named dentist
Transfer records to:

MARLENE FEISTHAMEL, DDS, PC
Feisthamel Family Dentistry
5469 S. State Hwy FF, Battlefield, MO 65619
Phone: 417-447-5180
Email: info@feisthameldds.com

5469 S. State Hwy FF

Battlefield, MO 65619

417-447-5180

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