Transfer of Medical Records

Please ensure you add your previous Dr/Clinic we are requesting your records from

Patient Details

First Name

Last Name

Date of Birth

Address

Street Number and Name *

Suburb *

State *

Postcode

Medicare

Medicare Card Number

Expiry Date *

Position on Card *

Patient's Previous Practice Details

Name of Previous Practice *

Practice Phone Number *

Practice Fax Number

Consent to Transfer Medical Records

All existing recordsAllergies & adverse reactionsCurrent medicines listMedical history (current and past active and inactive) as recordedFamily history as recordedSocial history as recordedHealth risk factorsImmunisations as recorded
I authorise for this release to be
to [Clinic details] in a XML file"]
I give consent for my medical records to be released to this practice *