Choice Dental

AUTHORISATION FOR RELEASE OF PROTECTED HEALTH INFORMATION - DENTAL RECORD

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Address(Required)

PATIENT AUTHORISATION

I, do hereby authorize
to release a copy of my dental records, x-rays and those of my dependents (if applicable), and release them to Choice Dental Browns Plains - send records to enquiries@choice-dental.com.au
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Clear Signature
If signed by anyone other than the patient, state the relationship to patient and/or reason and legal authority for signing. (Proof required) Patient is: