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804 N. Main Street #201A, Rochester, MI 48307 | Directions
Dentists in Rochester Hills - Young Couple

Radiograph and Records Request

Print blank form to fill by hand
** Please fill out this form only to request records from a previous dental office and mail or fax it to that office.
*Patient Name :
*Last Name :
Middle Name : *First Name :

Dear Doctor,
Please accept this document as my formal request to have my most recent radiograph and dental records forwarded to the practice of Dr. John L. Aurelia at the following location:
John L. Aurelia, D.D.S., PLLC
804 N. Main Street #201A
Rochester, MI 48307
Email:frontdesk@aureliadds.com
Thank you for your assistance in this matter.

*Patient’s Signature
Date

Patient Review

Rating: 5Dentist Rochester Hills - 5 Star Rating
Dr. John Aurelia Reviewed byJeanette Jacobs

" Dr Aurelia and his staff are very professional and deliver a high level of care. Questions are always answered with understanding and kindness. I am so pleased with the care delivered by Dr Aurelia and his staff."
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Dr. Aurelia has been voted by his Peers to be included in the 2014 DatAbase of Dentists in Rochester Hills - Top Dentist Logo
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