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Request to access Orthodontic Medical Records

Under privacy law, clients have rights of access to their information held about them by this practice. We are pleased to assist in providing clinical information required for your ongoing orthodontic and health care to other health professionals when requested by them on your behalf.

Authorise my orthodontic records to be released to the following parties.

Name of Person or Facility*

Address*

Relationship to Patient*

Phone Number

Please Select all specific documents that apply to your request.

OPG x-ray Lateral Ceph x-ray Clinical photographs

I understand that I will not be permitted to remove the original contents of my record from the premises of the practice, nor will I be permitted to alter or erase information contained in the record.

If any further information is required please send an email to our reception team via email customerservice@smileteam.com.au

Date

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