Record Release Form

Before continuing, I understand that in requesting a copy of my dental records, the records will be:

The records will be emailed and/or posted to my nominated address.
Receiving by email may not be as secure as receiving the records personally or by post.
Beenleigh Marketplace Dental accepts no liability for your records once they leave our practice.
Beenleigh Marketplace Dental accepts no liability for the records if they are accessed by an unauthorised source during transit, or in any other manner whatsoever.
I can ask for a copy of my records to be provided to me personally or by post if I am sufficiently concerned about email security.
If I have any further questions, I can contact Beenleigh Marketplace Dental via phone or email.

Name(Required)

First Last

Date of Birth(Required)

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

I am requesting a copy of…(Required)

My dental records / a summary of my dental records.

My child’s/children’s dental records.

Both mine and my child’s/children’s dental records.

I would like my records to be…(Required)

Given to me in person

Posted to me at the above address (at my own cost)

Posted to my dental practitioner (at my own cost)

Emailed to me at the email address above.

Emailed to my treating dental practitioner.

Name of previous clinic(Required)

Email of previous clinic

Dental Practitioner's Address(Required)

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Signed(Required)

Please print your name.

Date Signed(Required)

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Dental Records Release Form Beenleigh