MY DOCTORS CLINIC
SURFERS PARADISE

16/3221 Surfers Paradise Boulevard, Surfers Paradise, QLD 4217 · P (07) 5592 2299

Request for Transfer of Medical Records

Fill in the form, sign with your finger or mouse, then tap Create signed form. Nothing is sent anywhere until you choose to send it.

Your details

Title

Date of birth *

Family name *

Given name *

Address Mobile number *

Previous clinic to transfer records from

Clinic name * Clinic address

Clinic phone

Clinic fax

Receiving clinic & doctor

I request that a copy of my medical history is sent to the clinic below. If sending the records electronically, please send in an .xml format.

Doctor name

My Doctors Clinic Surfers Paradise
16/3221 Surfers Paradise Boulevard, Surfers Paradise, QLD 4217
Phone 07 5592 2299 · Fax 07 5539 9188
surfersmanager@mydoctorsclinic.com.au

Last assessment or review

Please tick if completed and record the date of the last assessment or review.

Please send via Medical Objects to

Authorisation & signature

I understand that a fee may be charged for the cost of providing access or copies.
I hereby authorise the release of my medical history to My Doctors Clinic Surfers Paradise.

Signature of person requesting *

Sign here with your finger or mouse

Date

Your signed form is ready

Send it to the clinic by email to surfersmanager@mydoctorsclinic.com.au, or bring it in.