412 Old Cleveland Road, Coorparoo QLD 4151 · 07 3398 5885

Permission to request your child’s dental records

So your child’s dentist here has the full picture on the day, we need your permission to ask their previous dentist for their records. It takes about a minute.

Child’s full nameChild’s date of birth

Your address — the child’s home addressDate of their appointment with us — if you know it

Previous dentist’s nameTheir practice nameTheir practice addressTheir practice email address — this is where we send the request, so it matters mostYour name

I, …, hereby authorise Dr … of … to release my child, …'s dental records or copies thereof (including radiographs and photographs where applicable) to: Tooth Town, 412 Old Cleveland Road, Coorparoo QLD 4151. Email: info@toothtown.com.au Phone: 07 3398 5885

Sign here

We only use this to ask your previous dentist for your child’s records. Questions? Ring 07 3398 5885.