Healthicare Transfer of Medical Records Consent

PATIENT DETAILS

First Name

Last Name

Date of Birth *

Contact Phone *

Address

Email address Verification *

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External Medical Practitioner or Practice Name *

Address

Practice Email Address

Practice Phone Number

Practice Fax Number

Do you also wish to transfer records for any of your children or dependants? (Any patients aged 16 years and over must complete their own form) *

YesNo

If you answered yes, please provide us with the full name and date of birth for each of your dependants below

I confirm that above information I have provided is true, complete and accurate. *

Patient/ Guardian Signature

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