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    patient authority to transfer records from another practice

    Dear Patient,

    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

    to seek copies of my dental records from Dr


    Date of Birth:



    Once completed please print, sign, and scan or take a photo of the signed form and email to or drop it off at the practice.

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