Transfer of Medical Records

Name*
Patient D.O.B.*
DD slash MM slash YYYY
Address of Patient*
Street Address Address Line 2 City
Patient's previous clinic/GP to get patient history (required for us to REQUEST patient history)*
Name of clinic/GP you would like us to send patient history to*
Name of clinic/GP you would like us to return patient history to*
Email*
Phone*
Fax
Date*
DD slash MM slash YYYY
Signature*
Please include the following
Health Summary Investigation Reports All Existing Records Health Assessment Immunisation History GP Care Plan (721) Visit Notes Team Care Arrangement (723) Specialist Letters
I authorise for this release to be;*
- Faxed to the requesting practice - (03) 4245 2188
- Sent by mail to the requesting practice

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