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.