Authorization and Request for Previous Dental Records and Radiographs Authorization and Request for Previous Dental Records and Radiographs Previous Dentist * Address * City * State * Zip * Phone Number * Please forward any previous x-rays and/or records as soon as possible to: Nicollet Station Dental 510 Marquette Ave. S. Minneapolis, MN 55402 info@nicolletstationdental.com 612-338-5557 Fax: 612-373-0602 Signature * Clear Name * Today's Date Submit
