Records Release from eDentistry

Contact Details

TitleMrMrsMsDrOther

Patient First Name *

Patient Last Name *

D.O.B. *

Your Email *

Street Address:

Suburb:

State:

Postcode:

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:

Street address:

Suburb:

State:

Postcode:

Copies of the following are specifically requested:

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

Your Signature