AUTHORISATION TO TRANSFER RECORDS TO TREASURY MEDICAL

AUTHORISATION TO TRANSFER RECORDS TO TREASURY MEDICAL
Details of the Practice you wish to transfer from.*
Practice Name, Phone Number, Address etc.
Name*

First NameLast Name
Date of Birth (DD/MM/YYYY)*

DayMonthYear
Address

Street Address

Street Address Line 2

CityState

Post Code
Phone Number
Please enter a valid phone number.
Dependents under 18 Years. Include Full Name & DOB.
Please include the details of each dependent you wish to transfer to Treasury Medical
I am now attending Treasury Medical and would appreciate my records being transferred electronically in .xml format to admin@treasurymedical.com.au. I authorise Treasury Medical to obtain a copy of my medical records.

Agree
Date*

DayMonthYear
Date
Signature

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Treasury Medical

"Treasury Chambers"

32 Davey Street, Hobart TAS 7000

P - 03 6124 2727

F - 03 6124 2728

E - admin@treasurymedical.com.au

www.treasurymedical.com.au
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