PATIENT REQUEST FOR DENTAL RECORDS FORM
I, hereby authorize my doctor to release my dental records or copies thereof ( including radiographs and photographs where applicable)
( If applicable) and those of my following dependants:
And provide such records to Casuarina Dental Family and Holistic Care.
I undestand that the release of these of confidential records is at discretion of the treating dentist and that the original records remain the proprerty of the Dentist/Practice who created them.
The Commons, Shop 9/10 480, Casuarina Way, Casuarina - NSW TEL 02 6678 2220, www.casuarinadental.com.au email: firstname.lastname@example.org