Permission to Transfer Medical Record

Permission to Transfer Medical Record – Patient Details

Nisa Medical Centre 50 Arena avenue Roxburgh Park, Vic, 3064 T 03 8339 2797 F 03 8339 2637 info@nisamedical.com.au

Your Name

Date of Birth

Dependent name 1 (under the age of 16)

Date of Birth

Dependent name 2 (under the age of 16)

Date of Birth

Dependent name 3 (under the age of 16)

Date of Birth

Your address

City
State
Postcode

Permission to Transfer Medical Record - Previous Medical Centre Details

Name of GP/Medical Centre records to be obtained from

Contact Details (telephone, fax number or email)

Consent to Transfer Medical Record

	Yes
Nisa Medical / 50 Arena avenue Roxburgh Park, Vic, 3064 / T - 03 8339 2797 / F - 03 8339 2637 / info@nisamedical.com.au	Nisa Medical / 50 Arena avenue Roxburgh Park, Vic, 3064 / T - 03 8339 2797 / F - 03 8339 2637 / info@nisamedical.com.au
The patient with the details listed above is now attending Nisa Medical. Please attach the below listed requests in order to allow Nisa Medical to facilitate the patients ongoing care. If your practice uses Medical Director, kindly send all electronic data via MDExchange, or on a CD in XML format. Nisa Medical accepts DIGITAL RECORDS ONLY (NO HARD COPIES).	The patient with the details listed above is now attending Nisa Medical. Please attach the below listed requests in order to allow Nisa Medical to facilitate the patients ongoing care. If your practice uses Medical Director, kindly send all electronic data via MDExchange, or on a CD in XML format. Nisa Medical accepts DIGITAL RECORDS ONLY (NO HARD COPIES).
I request that a recent health summary, recent pathology, imaging and any specialist correspondence be transferred as soon as possible.	I request that a recent health summary, recent pathology, imaging and any specialist correspondence be transferred as soon as possible.
(under the age of 16), will also be transferred.	(under the age of 16), will also be transferred.
The information contained is confidential and may also be the subject of Medical Professional Privilege. If you are not the intended recipient, any use, disclosure or copying of this document is unauthorized. If you have received this document in error, please contact us on 03 8339 2797	The information contained is confidential and may also be the subject of Medical Professional Privilege. If you are not the intended recipient, any use, disclosure or copying of this document is unauthorized. If you have received this document in error, please contact us on 03 8339 2797

Signature

Date