Transfer of Patient Records
Patient Name
*
Mr.
Mrs.
Miss.
Ms
Master
Dr.
Prefix
First Name
Middle Name
Last Name
Patient Date of Birth
*
Patient Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Patient Contact Phone Number
*
Patient Email
example@example.com
I, the patient named above, hereby authorise the doctor and practice listed below to provide a digital copy (.xml format) of my medical health records to Currimundi Family Doctors to facilitate my further clinical care. *** Currimundi Family Doctors use Best Practice software and would appreciate a digital copy to help our doctors have access to clinically relevant information.
Any additional information to be noted:
Previous Practice Name
*
Previous Doctor Name
Previous Practice Email
example@example.com
Previous Practice Phone Number
-
Area Code
Phone Number
Patient Signature
*
Currimundi Family Doctors
768 Nicklin Way, Currimundi QLD 4551
Phone: (07) 53 141 321 Fax: (07) 5327 2277
www.currimundifamilydoctors.com.au
Submit
Should be Empty: