Medical Records Transfer Request

Medical Records Transfer Request
Your Details
Name

First NameLast Name
Date of Birth

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Would you like these records to be transferred to yourself, or directed to your preferred provider/clinic?

Recipient Details
Doctor/Practice Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Phone Number
Fax Number

Consent
By signing this form, I authorise you to release confidential health information about me to myself or the doctor / practice mentioned above, who is now responsible for my ongoing care.
Signature
Should be Empty: