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Records Release to eDentistry

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

We are currently still under restrictions, but can see patients for all necessary treatment WITH THE EXCEPTION OF regular maintenance (i.e. cleaning). Contact us for more information
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