Dr. Wael Garine, DDS
345 Jupiter Lakes Blvd. STE 304
Jupiter, Florida 33458
www.drgarine.com
Phone: 561-747-4272
Fax: 561-747-4294
E-Mail:www.drgarine.com

Request for Records

Date:
Account Number:
Account Name:
Patient Name:
Address:
City, State, Zip:
Phone:
Reason for leaving:

There is a balance of $ on your account, records cannot be released until balance is paid in full.

I hereby request the transfer of my records: To:         From:

Dr.
Address:
City, State, Zip:
Phone: Fax:
Authorized Signature: Date: