PATIENT RECORD TRANSFER REQUEST

Patient Details

Additional Family members (Who also require medical records from practice mentioned below)

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I/we am/are now attending Stratford Medical Centre.

Could you please forward a copy of my/our medical record/s to the practice at the address below .

I understand an administration fee may be charged for this service. If this is so can you please contact me directly at the above number.

Doctor Details: (Name of Doctor/Medical Practice I am requesting records from)

Requested ( Please Check )
Progress Notes

Health Summary

Specialist/Allied Health correspondence

Pathology/Imaging investigation results
I here by authorise my records to be sent to the above practice
Signature
Date
I further consent to both the sending practice and Stratford Medical Centre uploading to and accessing my web based My Health Record.
Signature
Date
Stratford Medical Clinic would really appreciate the transfer of records via upload to My Health Record or electronic transmission via secure messaging. Please note that the HealthLink EDI is stratfds.

2/1 Kamerunga Road, Stratford Qld 4870
Ph: 07 4058 2264 Fax: 07 4055 1567
Email: reception@stratfordmedical.com.au