Patient resources

Records release form

Moving to us from another dentist? Sign this authority and we'll request your records for you — X-rays, clinical notes and all. Takes about two minutes on your phone, no printing or scanning needed.

Your details

Full name *

Date of birth *

Mobile number *

We'll text you to confirm we've received this.

Your previous dentist

Practice name and suburb *

If you're not sure of the exact name, put whatever you remember — we'll find them.

Dentist's name, if you know it

Leave blank if you're not sure — it just helps them find your file faster.

What would you like us to request? Everything — notes, X-rays, photos and scans X-rays and imaging only Clinical notes only

Your authority

By signing below, you authorise your previous practice to release your records to Southside Dental Toowoomba.

I confirm I am the patient named above, or the parent or guardian entitled to make this request on their behalf *

Signature *

Sign here with your finger or mouse

What you send goes straight to our front office and is used only to request your records. We don't store this form on our website, and we never share your details with anyone other than the practice you've named above.

Back to patient resources

Questions about your records?

Your records belong to you, and your previous dentist is required to respond to a request within 30 days. If you'd rather do this over the phone, or you're not sure who your last dentist was, call us on 07 4635 1444 and we'll sort it out with you. You can read how we handle your information on our privacy page.

Records release form

Your details

Your previous dentist

Your authority

Thank you — we've got your signed form

Questions about your records?