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Patient Records Release Form

Please complete the form below to request Stratford Medical Centre send your records to your new GP.

    Patient Details

    Patient Name:

    Date of Birth:

    Address

    Phone:

    New Doctor/Practice:

    New Doctor/Practice Name:

    Address:

    Phone:

    Fax:

    Please send the following information to my new GP:

    If "Other" selected above, please list the specific information you are requesting:

    Date:

    Signature: