request medical records

Pulse Holistic Medical Centre
Request for Medical Records
Pulse Holistic Medical Centre Suite 1A, 68 Jessica Blvd Minyama Qld 4575
Dr Mark Fulton/ Dr Tracy Johns /Dr Nicole Nelson/ Danielle Roberts/Gina Wilson
Ph: 07 5477 5522 Fax 0754775599
Ph:
Date:

Day Month Year
Date
1 Patient name :
DOB

Day Month Year
Date
2 Patient name
DOB

Day Month Year
Date
Dear Dr
Practice Name
Phone
Fax
The above patients have recently come under the care of this surgery and have requested that a full/summary of records be forwarded to this surgery. Please forward any relevant records and immunisation history at your earliest convenience. Please do not send records on a disc. If applicable, could you please also advise the dates that any of the following have been billed:
GPMP (Items 721/723 or 732)
Health Asses (Item 707)
DMMR (Item 900)
Mental Health Plan (2715/2717 or 2712)
Yours Faithfully
I hereby authorise you to send my/our medical records to Pulse Specialist Medical Centre

Signature of patients named above
Signature

Clear
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Pulse Holistic Medical Centre