Dental Records Transfer Request

First Name *

Surname *

Date of Birth *

Is your previous dental practice located in the greater Darwin region? *

Name of Previous Dental Clinic *

Please note that we are unable to request your records without information about the name, location and email address of your previous practice fields being filled out.

Name of Previous Dental Clinic *

Practice Address *

Practice Email Address *

Practice Phone Number

Signature

Clear

I authorise the release of copies of my dental treatment records including copies of all relevant x-rays to be transferred to Dr Thien Pham at Compass Dental Care. Address: 102/12 Salonika St, The Avenue, Parap NT 0820 Telephone: (08) 8995 9530

If you are human, leave this field blank.