Medical Release Form

Medical Release Formadmin2022-03-09T05:18:18+10:00

I (name),

DOB:

of (address)

give authorisation to release my relevant medical history to: (please list doctor information)

Patient Signature:

Date:

I authorise for this release of any Discharge Summaries, Pathology results, Scans, Specialist Letters or any other relevant medical information.

Faxed to the requesting practice or

Sent by mail to the requesting practice

If you are human, leave this field blank.