Consent for Release of Medical Information
                                                 Date Faxed

The patient below attends Redcliffe Beach Clinic, We would be grateful if you could send the patients’ medical record at your earliest convenience by Medical Objects.
I hereby give consent for my medical record to be released to Dr ……………………………..
At Redcliffe Beach Clinic.

1 (a) Patient Details (please print in block letters)	
Surname:

	Given name(s):	
Address:

	

Date of birth: 		
Full Medical File   	Other Information Required:
	
2. Health Information Requested 
Medical Objects Preferred	

Signature____________________________Date:__________

1.	Requesting information from:

Name of 
Medical Practice __________________________
	
	Address:_________________________________

	Phone:  ___________ Fax: _________________

2.	Requesting information from:

Name of Hospital 
________________________________________________________