• Transfer records to another practice

    Use this form to ask us to send a copy of your medical records to another practice. You will need the new practice’s name and suburb, and a credit or debit card.

  • 01 WHOSE RECORDS ARE BEING SENT

  • Whose records are being sent?*
  • What gives you authority to ask for these records?*
  • We may contact you to confirm your authority. For a child or young person, we may also need their consent.

  • 02 PATIENT DETAILS

    The person whose records are being sent.
  • Date of birth*
     - -
    2 digit day, 2 digit month, 4 digit year

  • 03 CONTACT DETAILS

    How we can reach you about this request.
  • Format: 0000 000 000.
  • Best way to contact you*
  • Do you need the records by a certain date?
     - -
    2 digit day, 2 digit month, 4 digit year

  • 04 NEW PRACTICE

    Tell us where to send the records. Please give as much detail as you can. Fields marked * are needed for us to complete the transfer.
  • Format: 00 0000 0000.

  • 05 RECORDS TO SEND

  • Choose what you would like us to send. You pay by card when you submit this form. If you are experiencing financial difficulty, email records@stivesdoctors.com.au before you submit.

  • Records and fee*

    prevnext( X )
        Health summary

        Medical history, medicines, allergies and immunisations

        $15.00 AUD$15.00AUD
          
        Full medical record

        Complete copy of your medical record

        $30.00 AUD$30.00AUD
          
        Total
        $0.00 AUD$0.00AUD

      • 06 AUTHORITY AND SIGNATURE

      • Date*
         / /
        2 digit day, 2 digit month, 4 digit year
      • We may contact you to confirm your identity before we send anything. If you change your mind, email records@stivesdoctors.com.au as soon as possible. Records already sent cannot be recalled.

      • PRIVACY

        St Ives MC Pty Ltd trading as St Ives Doctors uses the information in this form to verify identity and authority and manage the requested record transfer. We may share the relevant request details and authority with the practice named in the form. If information needed to process the request is missing, we will contact you. Our Privacy Policy explains how we handle personal information and how to request access or correction or raise a privacy concern. For help, email records@stivesdoctors.com.au.
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