Records Release from eDentistry

Name: eDentistry Wantirna
Address: 271 Stud Rd, Wantirna South, VIC, 3152, and
Telephone: (03) 9800 1184

Contact Details

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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

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About Us

eDentistry Wantirna opened on May 2017 with a vision to provide a unique service to patients, through digital dentistry. Digitisation of dental procedures not only increases the precision and quality of the work, but can also improve the comfort and efficiency of the procedure for patients.

Servicing Suburbs

We service Wantirna South and its neighbouring suburbs which includes but not limited to: Vermont South, Wantirna, Bayswater, Glen Waverley, Boronia, Rowville Scoresby and Knoxfield.

Contact Details

Phone: (03) 9800 1184
Email: info@edentistry.net.au
Address: 271 Stud Rd, Wantirna South VIC 3152

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