Transfer of Medical Records Consent Form

First Name *

Last Name *

DOB *

Address *

Street address *

City *

State *

Postcode *

I hereby grant my consent for all medical records relating to me (and/ or my child) to kindly be forwarded from

Practice Holding your Records:

Clinic Name *

Clinic Phone Number *

Clinic Address *

Street address *

City *

State *

Postcode *

and transferred across to my new clinic.

Practice Name *

General Practitioner Name *General Practitioners full name that will caring for you

Practice Phone Number *

Practice Address *

Street address *

City *

State *

Postcode *

via our preferred method of email: langwarrin@montierhealth.com.au or via fax: (03) 9044 0015.

Date *

Signature *

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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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Date

Patient Name:

DOB

Signature

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Date

For security please complete the check below *