Request for transfer of Medical Records

Request for transfer of Medical Records

From Dr Raymond Mullins, Suite 1, John James Medical Centre, Deakin ACT 2600. Tel 02-6282 2689; Fax 02-6282 2526
Name of patient

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email (desirable as records can be sent by email)
example@example.com
Phone Number
Please enter a valid phone number.
Date of birth of patient

MonthDayYear
Date
Date of request

MonthDayYear
Date
Where to send the records

Patient (self)-this is the BEST option as you can take it to any new GPA medical practice (need contact/address details)
If to send to a medical practice that you are not already attending, please type in the practice name, address and other contact details (eg. fax, email)
OTHER TEXT
Should be Empty: