Records Release Form

Your name and date of birth
Your phone number
Today's date
Your former dental practice
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.