Medical Record Request and Consent

Request for Transfer of Medical Reports

    ATT DR/Medical Centre
    Phone:Fax:

    Patient Details

    Patient Name

    Date of Birth

    Dear Doctor,

    The Patient(s) listed are now attending this practice and have requested that his/her complete health record be forwarded to assist with their ongoing care.


    Requesting Doctor (Dr Nicholas Hummel):

    Please forward at your earliest convenience via Best Practice XML Format to email – admin@noosaheadsmedical.com.au


    Patient Consent (Dr Nicholas Hummel):

    I/We give permission for my/our medical records to be transferred to Noosa Heads Medical as this is the practice I am/we are now attending for medical care.


    Patient Name

    Date of Birth

    Minor

    YesNo

    Patient Signature

    Parent/Guardian Signature

    Patient Name

    Date of Birth

    Minor

    YesNo

    Patient Signature

    Parent/Guardian Signature

    Patient Name

    Date of Birth

    Minor

    YesNo

    Patient Signature

    Parent/Guardian Signature