Request for Medical and Dental Records

Request for Medical and Dental Records

I

Date of Birth

Address

Give permission to release all relevant clinical records and radiographs from:

Previous Dentist Name

Previous Practice Name

Previous Dentist/Practice Address

Previous Dentist/Practice Email Address

Previous Dentist/Practice Telephone Number

To

Dr Gareth Lewell
Captivate Dental
46 Station St, Moorabbin, VIC 3189
(03) 9553 1249
info@captivatedental.com.au

Patient or Guardian Signature

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Date