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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Practice holding your records
FROM: Current practice location:
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Practice holding your records
FROM: Practitioners full name:
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Practice holding your records
TO: Name of practice you're wanting your records sent to:
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General Practitioners name (taking over your care)
TO: Name of Practitioner (taking over your care):
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General Practitioners name (taking over your care)
via our preferred method of Medical Objects, email: admin@specialistnetwork.com.au or fax: 0756004978
Signature
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Type signature
Clear
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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Clear
Date
Patient Name:
DOB
Signature
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|
Type signature
Clear
Date
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