flindersdp.com.au - Dr. Chris Wooldridge - Records Release form (Consent Form)

Consent Form
Dear:
Dental Practice Name
Practice Phone Number
Practice Address

Street Address

Street Address Line 2

SuburbPostcode

Postal / Zip Code
Re:
Name

First NameLast Name
Date of Birth

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mobile Number
My patient has consulted this practice (Flinders Dental Practice) for ongoing dental treatment. We understand that you hold records pertaining to previous treatment.

To assist us in providing the most appropriate treatment, we ask for your help in supplying copies of dental records and relevant radiographs.

To ensure compliance with the State and Federal Legislation, the patient's signed consent to this request is supplied below.

We appreciate your assistance with this request. If you foresee any problems in providing the requested documents within the next week, please contact us as soon as possible.

Please advise the patient of any fees which may be incurred under the Privacy Regulations.

Thank you for your assistance.

Kind regards,

Dr. Chris Wooldridge
Dr. Paul Gleeson
Dr. Emma Barnsley
Dr. Julia Gellatly
Miss. Skye Greenhill
I give permission Dr Chris Wooldridge/Dr Paul Gleeson/ Dr Emma Barnsley/Miss Skye Greenhill only to seek copies of my dental records.
Signature*

Clear
Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
3/33 Cook St, | info@flindersdp.com.au | flindersdp.com.au | 5989 1129
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Consent Form