"*" indicates required fields Date of Request* DD slash MM slash YYYY Patient’s Full Name*DOB* DD slash MM slash YYYY Patient Address* Street Address Contact Number*Email* Which healthcare practice/hospital would you like us to share the information with?Which specific clinician or doctor would you like us to share the information with?Patient Signature*I hereby give authority for a transfer of a copy of my medical records to the above doctor/clinician by (Please circle) Fax Email Medical Objects Post Any of the options Special RequestsRequest for copy of medical records for work purposes- Reason for request and details of person you would like us to share the information with?We are happy to receive records via Medical Objects or by fax to 07 4927 4693. There is a $50 to $100 administration fee based on the quantity of information and admin time involved. This email/fax, including any attachments sent with it, is confidential and for the sole use of the intended recipient(s). This confidentiality is not waived or lost if you receive it and you are not the intended recipient (s) or if it is transmitted/received in error. Any unauthorised use, alteration, disclosure, distribution or review of this information is strictly prohibited. If you are not the intended recipient(s) or if you have received this faxed in error, you are asked to immediately notify the sender by telephone 07 4887 5123 by return fax on 07 4927 4693. You should also delete this fax/email and any copies from your computer system network and destroy any hard copies produced. You must not copy, distribute or take any actions that relies on it, any form of disclosure, modification, distribution and a publication of this fax is also prohibited.
