REQUEST FOR COMPLETE DENTAL RECORDS

    The above patient has consulted with this practice for on-going dental treatment. We understand that you hold records pertaining to their previous treatment.

    To help us to provide the appropriate treatment, we ask for your assistance in supplying a copy of relevant records and radiographs. To ensure compliance with State and Federal Privacy Legislation, the patient’s signed consent to this request is supplied below.

    We hope to schedule an appointment for this patient within the next few weeks, and would therefore appreciate you attending to this request within the next week if possible. If you foresee problems in providing assistance, please contact us at your earliest convenience.

    Please advice of any fees which may be incurred under the Privacy Regulations and make the account out in the name of the patient.

    Thank you for your assistance.

    Yours Sincerely

    Dr. Richard Thean

    Consent Patient

    I give permission for Dr. Richard Thean acquire my complete dental records/radiographs from my Dentist

    I agree to pay any fees incurred in the copying process, as defined in the Privacy Regulations (Victoria).

    Signature of Patient

    Name of Patient

    Date