Dr Franco Patient Transfer form

TRANSFER OF PATIENT RECORDS
I, the patient named below, hereby authorise Pulse Holistic Medical Centre to provide a digital copy (.xml format) of my medical health records to Currimundi Family Doctors to facilitate further care by Dr Franco Ambrosio. I understand that Pulse Holistic Medical Centre may retain a full copy of my records to facilitate further care of regular General Practice services received by doctors other than Dr Ambrosio.
Patient Name*

First NameMiddle NameLast Name
Date of Birth*
Patient Address

Street Address

Street Address Line 2

CityState

Post Code
Contact Phone Number*
Email Address
example@example.com
Any additional information to be noted:

0/1000
Patient Signature*

Clear
DateTime
Currimundi Family Doctors

768 Nicklin Way, Currimundi QLD 4551
Phone: (07) 53 141 321 Fax: (07) 5327 2277

www.currimundifamilydoctors.com.au
Should be Empty:

TRANSFER OF PATIENT RECORDS