Dear Doctor,
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.
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.