Record release consent

Name: Ipswich Orthodontics
Telephone: 07 3812 0865

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Date of birth*

I do/do not consent to the release of my/my child’s (if under 16yrs of age) dental records to my /my child’s dental practitioner / dental specialists/ medical practitioner, during the time being treated by Ipswich Orthodontics. I DO consent I DO NOT consent

Date*

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Patients Signature