Records Release Form

    I hereby authorize the release all dental records for myself and the family members below

    to Storyville Family Dentistry
    815 N Causeway Blvd., Metairie, LA 70001

    These records include all, but are not limited to: Radiographs/Photos, Health History, Dental Health Status, Treatment Records, Prescription Records, Reports. This consent is effective until I provide written authorization to cancel this consent.