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
2 digit day, 2 digit month, 4 digit year
Address

Street Address

Street Address Line 2

CityState

Post Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
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.
Date

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Signature
Please verify that you are human
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
Should be Empty: