docGrace Dental 12425 55th St N Lake Elmo, MN 55042 phone 651
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Grace Dental 12425 55th St N Lake Elmo, MN 55042 phone 651
Grace Dental 12425 55th St N Lake Elmo, MN 55042 phone 651 430-1020 fax 651 439-2201 [email protected] Request for transfer of Patient Information. Today's date: Attn: Previous Clinic Name please print Patient(s) name(s) DOB / / DOB / / DOB / / Please forward current x-rays, patient history, unfinished treatment plans and current specialist correspondence to the following dental clinic: Grace Dental at the address above Dates of last Exam Prophy BWX FMX check if this request needs immediate attention due to an appointment soon. Date of appointment Signature of authorized requestor
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