Records Release from eDentistry

Contact Details

TitleMrMrsMsDrOther

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:

Copies of the following are specifically requested:

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

Your Signature