Patient Authority to Release Dental Records

Patient Authority To Release Dental Records

In signing this form, I hereby authorise my previous treating dentist at Oracare to release my dental records or copies thereof (including radiographs and photographs where applicable) and those of my dependants (if applicable), and to provide such records by registered mail, courier or personal delivery to the requesting doctor.

Patient Name(Required)

First Last

Name of Parent or Guardian (if required)

First Last

Email(Required)

Phone(Required)

Address(Required)

Address Line 1 Address Line 2 City State Postcode Country

Patient Date of Birth(Required)

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Consent Form

Patient Consent(Required)

I have read and agree to the terms and conditions stated on this form.

Parent/Guardian Consent(Required)

I have read and agree to the terms and conditions stated on this form.

Hidden

Date Signed

https://oracare.com.au/patient-consent-forms/patient-authority-to-release-dental-records/

Phone

This field is for validation purposes and should be left unchanged.

Oracare

Patient Authority to Release Dental Records

Patient Authority To Release Dental Records

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