to disclose and provide copies of any and all clinical records including but not limited to x-rays, perio charting and chart notes to the following:
BlueSky Dental
2500 West A Street Suite 204
Moscow ID 83843
info@blueskydentistry.com
208-882-9111 (Phone) 208-882-3279 (Fax)
(Please email x-rays and history, including all placement dates for crown, bridges, etc if possible)
I expressly release from liability the above named person or entity from any and all liability arising from compliance with this request and disclosure of the requested information.