Request for Dental Records Call (03) 5443 5631 Your DetailsDetails of the person completing this form.Name* Given Names Surname Email* Mobile*Residential Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Patient DetailsDetails of the patient whose dental records are to be transferred.Patient Details*Full name and Date of Birth. List all patients here.Transferring Dentist DetailsDetails of the dentist from whom the dental records are being requested.Dentist's Name* Practice Details*Address, Email and Phone NumberConsent & Authorisation* I consent.I hereby consent and request the transferring dentist whose details are as above to transfer the copies of existing dental records, radiographs and any details of previous treatment(s) for all patients mentioned on this form above to: Integrated Smiles 93 Myrtle Street Bendigo VIC 3550 Email: reception@integratedsmiles.comSignature*Date* Day Month Year
