Transfer of Medical Records Consent Form
First Name
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Last Name
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DOB
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Email:
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I hereby grant my consent for all medical records relating to me (and/ or my child) to kindly be forwarded
FROM: Current practice holding your records:
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FROM: Practitioners name:
TO: Name of practice your wanting records sent to:
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TO: Name of Doctor (taking over your care):
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via our preferred method of Medical Objects or post. Thank you!
Signature
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Date
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Additional Family Members - you may sign for your child/ patient under your legal guardianship if they are minor/s:
Patient Name:
DOB
Signature
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Patient Name:
DOB
Signature
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Date
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