Authority to Release Dental Records

Release of Records to Blackall Terrace Dental

Patient first name:

Patient last name:

Patient date of birth:

I request these records be sent directly to Blackall Terrace Dental using their contact details:

info@blackallterracedental.com.au

Phone: (07) 5441 3583

Address: 87 Blackall Terrace, Nambour, QLD 4560

I have read and understood the above. I understand that the release of these confidential records is at the discretion of the treating dentist or practitioner and that the original records remain the property of the dentist or practitioner(s) who created them.

Yes

Your Signature

Thank you. Your request has been sent to Blackall Terrace Dental who will coordinate the next steps. PleaseCLICK HEREto close.

I, the above named, hereby authorize the release of my dental records or copies thereof including radiographs, clinical notes, dental charts and photographs and those of my dependents to Blackall Terrace Dental.

Yes

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Practice phone number

Practice e-mail address:

Practice address

Authority to Release Dental Records

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