Authority to Release Dental Records Form

Name: Wired Orthodontics
Address: Suite 6 Level 1 1220 Sandgate Road, Nundah, QLD, 4012, Australia
Telephone: 07 3260 6855

Fields marked * are required.

Patient First Name *

Patient Last Name *

Patient Email *

DOB *

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*

Phone *

Email *

Parent or Legal Guardian Name

Date*

Signature of patient or Legal Guardian:

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Find us in Nundah

Wired Orthodontics
1359 Sandgate Road
Nundah QLD 4012
Free parking available

07 3260 6855