I, First Name Last Name , hereby authorise Dr. , of Dental practice, to release my dental records or copies thereof (including radiographs and photographs where applicable).
And to provide such records to:
Dr. Mark Calvert
New Farm Dental Studio
P.O. Box 1490
New Farm QLD 4005
07 3254 3222
info@newfarmdentalstudio.com.au
I understand that the release of these confidential records is at the discretion of the treating dentist and that the original records remain the property of the dentist who created them.
Signed: Signature Date: Date Full Name: First Name Last NameDOB: Date Address: Street Address Address Line 2 City State Zip