Document ID: d801b20a1d26a5dddd2e661f7c089197af53ccd3
November 16, 2017
Signed On : https://setzerandcochran.com

Records Release - Katherine Fearing


Setzer, Cochran, Soares, & Hubbard Pediatric Dentistry

Barry P. Setzer, D.D.S. Stephen D. Cochran, D.M.D.
Flavio M. Soares, D.D.S. Karen A. Hubbard, D.D.S.

Name & Date of Birth of Child/Children:

1) Patients’ Name:  Sara Fearing  Patient’s DOB:  8/14/1998 
2) Patients’ Name:  Matthew Fearing Patient’s DOB:  2/7/2002 
3) Patients’ Name:    Patient’s DOB:   
4) Patients’ Name:    Patient’s DOB:   
5) Patients’ Name:    Patient’s DOB:   

 

Requester/Primary Guardian:

Katherine Fearing

Requester’s Email:

fearing4jax@aol.com

Information authorized for release:

  All records, including x-rays, etc. 

Reason for release of records: 

  Provider change. 

Please provide records via:

  send-to-email
fax
 

Send records to:
Authorized Recipient: Dr. Greg Archambault 

Authorized Recipients’ Fax: 904.730.2554 

Authorized Recipient’s Phone: 904.269.3842 

Authorized Recipient’s Street Address:  1414 Kingsley Avenue    Apt/Suite:  2 

City:  Orange Park    State:   Florida     Zip:  32073

Authorized Recipient’s Email: office@drarchambault.com 

 

Document must be signed by Parent/Guardian (or if patient 18 years or older they must sign)

November 16, 2017

8355 Bayberry Road ▪ Jacksonville, Fl 32256 ▪ Phone (904)733-7254

Signed by Katherine Fearing
Signed on:November 16, 2017

Signature Certificate
Document name: Records Release - Katherine Fearing
Unique Document ID: d801b20a1d26a5dddd2e661f7c089197af53ccd3
Katherine Fearing
Party ID: 800de548-aa98-4184-82a3-88ce7359a2c7
IP Address: 108.248.207.22
Security Level: E-mail
Digital Signature:
Multi-Factor
Digital Fingerprint Checksum
8f76ff5ba9afec60fb8cb12f1db32a65
Timestamp Audit
2017-11-16 11:45:38 ESTRecords Release Uploaded by Barry Setzer - awillson@setzerandcochran.com IP 50.73.244.114
2017-11-16 11:45:45 ESTDocument viewed by Katherine Fearing - fearing4jax@aol.com IP 108.248.207.22
2017-11-16 11:47:09 ESTDocument signed by Katherine Fearing - fearing4jax@aol.com IP 108.248.207.22
2017-11-16 11:47:10 ESTThe document has been signed by all parties and is now closed.
2017-11-20 08:20:56 ESTDocument viewed by Katherine Fearing - fearing4jax@aol.com IP 54.196.2.131