Dental Records Transfer Request

First Name *

Surname *

Date of Birth *

Is your previous dental practice located in Darwin? *

Name of Previous Dental Clinic *

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

Name of Previous Dental Clinic *

Practice Address *

Practice Email Address *

Practice Phone Number

State which your previous practice was located

Suburb of your previous practice (if known)

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

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