VITA - REQUEST FOR TRANSFER OF MEDICAL RECORDS

Vita Health Care

1281 Nepean Hwy, Mount Eliza 3930

Ph: 5972 2444

Fax: 9787 2906

Email: reception@vitahealthcare.com.au

REQUEST FOR TRANSFER OF MEDICAL RECORDS

To *(Medical Practice Name)

(Medical Practice Address)

Practitioner *(Dr's/Clinician's Name)

Fax

Information required:(ie. entire medical summary, discharge summary, medication list, etc)

Add Another Clinic

To: *(Medical Practice Name)

(Medical Practice Address)

Practitioner *(Dr's/Clinician's Name)

Fax

Add Another Clinic

To *(Medical Practice Name)

(Medical Practice Address)

Practitioner *(Dr's/Clinician's Name)

Fax

Dear Practitioner,

The patient named below has authorised Vita Health Care to request relevant medical records to assist with their assessment and ongoing care.

We would appreciate you forwarding the information specified above to Vita Health Care using the contact details provided.

Records to be forwarded to:

To be released to the following clinicians (please select) *

Dr Sanil RegeDr Dhara PereraDr Fran MurdochDr Ruwan HaputhantrigeDr Ricardo PeraltaDr Victor OjoDr Mary MaduTracey GemmellMelissa GiaquintaJennifer McGowanMichelle CairnsErrol AkyalcinKate LuttickChaille BosCaitlin BleekerAny clinician as required at Vita Health Care

Patient Name *

D.O.B. *

Address

Date

I authorise the medical practice(s) and practitioner(s) identified above to release the medical information specified in this form to Vita Health Care for the purposes of assessment, treatment and continuity of care.

Patient Signature

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I am signing on behalf of the above patient as carer/guardian

Carer/Guardian Signature

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Relationship to patient:

Please include other members of my family (18 years and under) as listed:

D.O.B.

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