Records Release Consent Form

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Choose Your Doctor

Doctor

Dr Sam Huang
Dr Joon Park
Bob Rho
Nimra Asfar

Existing Clinic Details

Clinic Name

Clinic Phone Number

Clinic Email Address

Your Personal Details

Full Name

Address

Date Of Birth

Phone Number

Consent

I have consented to have my dental records forwarded to Brisbane dental and Denture clinic via email : brisdentalclinic@gmail.com

I would also like the following family members to be included:

Name

Date Of Birth

Name

Date Of Birth

Name

Date Of Birth

I request for you to provide the following:

Records

My dental clinical notes
My X-Rays, scans

Acknowledgement

I acknowledge that the email transmission cannot be guaranteed to be secure and error-free, I release both practices from all liability relating to any data breach associated with the transmission of the records by email across the internet or the security of the recipient’s email account.

Signature

Clear Signature

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