Patient Notes Transfer Form

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,