Records Release to eDentistry

Please fill in this questionnaire to be submitted with a referral to the Sleep Clinic.

Contact Details

TitleMrMrsMsDrOther

Request and authorisation for release of dental records to eDentistry Wantirna

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

Copies of the following are specifically requested:

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

Your Signature