Release Dental Records Form

Name: Wired Orthodontics
Telephone: 07 3260 6855

By filling out the form below, you give us the authority to release your dental records as needed to assist in your orthodontic treatment.

Please fill in all fields marked with *

Patient First Name*

Patient Last Name*

Patient Email*

Patient Date of Birth*

Patient address

Previous Dentist Name *

Dental Clinic Name *

Clinic Address*

Clinic Phone *

Clinic Email *

I authorise the above Dentist/Orthodontist to release all patient records including X-rays, photos, clinic notes to the Dentist/ Orthodontist below:

Dentist Name *

Practice Name *

Address*

Email *

Phone *

Parent or Legal Guardian Name

Date*

Fields marked * are required.

Signature of Patient or Parent/Guardian (If patient is under the age of 18)*

By clicking submit, you are agreeing to our privacy policy

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