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Release of Medical Information

Title *

First name *

Surname *

Gender *

Best Contact Number *

Date of Birth *

Address *

Email Address *

Today's date *

Please provide details of your previous doctor

Doctor name

Clinic name *

Clinic address *

Phone no *

Fax no

I am now am attending MINT Clinic, Suite 2, 255 Wellington Street, Collingwood, VIC 3066

I see the following doctor *

I consent to the transfer of my medical records to:

MINT Clinic
Suite 2, 255 Wellington Street
Collingwood Vic 3066

Your Release of Medical Information request will now be forwarded to the MINT Clinic reception team. We will sent your request to your previous medical practice. Please note: the release of your file may take 7 to 14 days.

Patient signature *

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Transferring clinic

We request notes are sent in pdf format. Please sent patient file to:

FAX: 03 9923 6445

POST: MINT Clinic
Suite 2, 255 Wellington Street
Collingwood Vic 3066