In assisting us in providing the most appropriate treatment, we ask for your help in supplying a copy of relevant dental charts, radiographs and clinical notes.

Please advise of any fees which may be incurred under the Privacy Regulations and make this account out to the name of the patient.

Patient Details

Records are also being requested for the following family members:

Please forward records to: info@ballaratdentalgroup.com.au

Patient Consent

I give permission for the Partners of Ballarat Dental Group to see copies of my / families dental records. I agree to pay any fees incurred in the copying and process, as defined in the Privacy Regulations.

PRACTICE USE ONLY