Transfer of Record Form

Suite 2, 4 Makin Place, Deakin ACT 2600

T: 02 6185 5555 F: 02 6147 0311

E: deakin@nextpracticehealth.com

Healthlinks EDI: nxtpracd

Transfer of medical records request

Previous GP details

GP *

Address *

Telephone *

Fax

The patient below is is attending our practice and we would appreciate for their records as indicated below and reports to be forwarded for their ongoing care and management. Please send by secure electronic transfer or by registered post.

Patient details

First Name *

Last Name *

DOB *

Gender *

MaleFemaleOther

Address *

Contact Number *

Would you like to request transfer of records for children under age of 16?

Name *

DOB *

Gender *

Click to add another child

Name *

DOB *

Gender *

Click to add another child

Name *

DOB *

Gender *

Patient Consent

I give my permission for:

a HEALTH SUMMARY of my medical records to be released to the above doctor's clinic. *

my full records to be released to the above doctor's clinic and agree to pay the related costs involved if applicable.

I consent to volunteer registration under MyMedicare (from 1/10/23). For more information visit https://www.health.gov.au/our-work/mymedicare

Signature *

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Date