In providing the most appropriate dental treatment for you in our practice, we believe it would be of great assistance to access information about your dental treatment from your previous practice:
To ensure compliance with the Federal and State Privacy Legislation we require your signed consent to authorise these records.
Please be aware that it is lawful for a practitioner to charge a fee to a patient requesting access to, and copies of, written records and other forms of diagnostic records such as radiographs, etc. Any accounts which may be issued for these purposes will require your payment.
I give permission for Dr
SelectDr Shehan Warusevitane BDSDr Susan Portbury BDScDr Liban Mohamed DDSDr Adrian Bendekovic DDSDr Irena Koneski DDM
to seek copies of my dental records from Dr
I agree to pay any fees incurred in the copying process, as defined in the Privacy Regulations (we do not charge a fee, your previous practice may).
Date of Birth:
Once completed please print, sign, and scan or take a photo of the signed form and email to email@example.com or drop it off at the practice.
Print This Form
A fee may be charged for appointments cancelled without 48 hours notice.