Lotus Holistic Medicine Patient Notes Transfer Form v1.0

Patient Notes Transfer Form
DayMonthYear
Lotus Holistic Medicine
5/13 Norval Ct,
Maroochydore QLD 4558

Dear Practice Manager,
I, name* , with date of birth Date* and address Street Address* City* State* Zip* hereby give authority and full consent for a copy of my FULL medical history, notes, imaging and pathology results to be released to WillowVale Clinic for my ongoing medical care.

Please provide a copy of my complete medical history, including
correspondence, investigations, and consultation records in electronic format, where available, in both XML and HTML formats, to the email address below as soon as possible.

info@willowvaleclinic.com.au

Thank you kindly,
Name*

First NameLast Name
Signature*
Email*
example@example.com
Date

DayMonthYear
Date
Should be Empty: