Contact Details

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Patient First Name *

Patient Last Name *

D.O.B. *

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Request and authorisation for release of dental records from eDentistry Wantirna

I hereby express written consent and request that all my dental and medical records be released from eDentistry Wantirna to:

Receiver's name:

Receiver's e-mail:

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Copies of the following are specifically requested:

Medical history form
Progress notes
Letters and reports to/from specialists
Periodontal charting
Radiographs
Other

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Records Release from eDentistry