Patient Authority to Release Dental Records

By completing this form you give Preventive Dentistry authority to request your dental records from another dentist/dental practice on your behalf.

Records FROM Practice/Dentist Name

Practice Contact Number:

Your Name:

Your DOB:

Your Address

Address Line 1

City/Suburb

State

Postcode

Country

Your Contact Number:

I hereby authorise and direct release of my records (including radiographs) to Preventive Dentistry.

Signature

Signature: