Patient Authority Form

>Patient Authority Form

By filling out this form, you authorise your doctor to release your dental records or copies thereof (including X-rays and photographs if applicable) and to provide such records to:

Dr Claud Capelli

39 Samuel St.,

Camp Hill, QLD., 4152

YOU UNDERSTAND THAT RELISE OF THIS CONFIDENTAL RECORDS IS AT THE DISCRETION OF THE PREVIOUS TREATING DENTIST DOCTOR AND THAT THE ORIGINAL RECORDS REMAIN THE PROPERTY OF THE DENTIST WHO CREATED THEM.

Download the form Patient Authority to Release Dental Records. Sign and email back to us via the email address specified in the document.