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: