Medical Authority

Medical Authority
To whom it may concern,

I authorise your practice to provide the Sydney Spine Institute clinic with any documents pertaining to my medical history including copies of all the clinical records, pathology reports, radiology scans, reports and investigations contained in my medical file held by your practice.
Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Should be Empty: