Consent To Release

First Name *

Last Name *

What is your Address? *

Street address *

City *

State *

Postcode *

What is your Date of Birth? *

Email Address *

Medical is your Medical Practice Name? *

What is the medical practice address? *

Street address *

City *

State *

Postcode *

What is your GP's Name? *

Dear Doctor,

Re: Request for transfer of patient medical records

As the patient listed above now attends this practice, please forward acopy of their medical records (or a complete and accurate healthsummary) and any other relevant clinical information to assist in thecontinued management of their healthcare.

I the abovementioned patient, consent to the release of my medical records and any other relevantclinical information to Optimal Health Clinic. info@optimalhealthclinic.com.au *

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Release Details:

Optimal Health Clinic11/2563 Gold Coast hwy, Mermaid Beach, QLD, 4218

info@optimalhealthclinic.com.au