www.smileinstyle.com.au - Patient request for records from another practice

Patient request for records from another practice
Dental Practice Name*

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Address*

Street Address Line 2

CityState / Province

Postal / Zip Code
Practice Email*
example@example.com
Practice Phone Number*
Please enter a valid phone number.
Dear Doctor,
Patient Name*

First NameLast Name
Gender*
If "Other" Please Specify
I wish to transfer my dental records to the Smile in Style Dental Practice at 9 Dornoch Drive Sunbury or 821 Mt Alexander Rd Moonee Ponds 3039 and provide my signed consent below.
Patient Consent
I of Birth Date Date give permission for Smile In Style to seek copies of my dental records, photographs, and x-rays from your rooms.

I am aware that it is lawful for a practitioner to charge fees to a patient requesting access to, and copies of, written records and other forms of diagnostic records, such as radiographs, etc. I agree to pay any fees incurred in the copying process, as defined in the Privacy Regulations.
Signature*

Clear
Name*

First NameLast Name
Date*

DayMonthYear
Date
Should be Empty:

Patient request for records from another practice