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Patient Records Transfer Request Form

Please complete the form below to request your medical records from your previous doctor/practice, and have them send to Stratford Medical Centre.

    Patient Details

    Patient Name:

    Date of Birth:

    Address

    Phone:

    Previous Doctor/Practice

    Previous Doctor/Practice Name:

    Address:

    Phone:

    Fax:

    Please send the following information to my new GP at Stratford Medical Centre:

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

    Date:

    Signature: