Medical History Transfer request

Her Medical History Transfer Request

30 Yacht Street, Southport 4215

Phone: 07 5616 8070 Fax: 07 5616 8069

Email: reception@hermedical.com.au

A copy or summary will be forwarded to Her Medical for continuity of your care.

Your medical history will remain at your previous clinic for 7 years from the last consultation or until a child turns 25.

First Name *

Last Name *

D.O.B *

Email Address *

Patient Address *

Patient Signature *

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Date *

Please enter the details of your previous clinic you are wanting to request FROM

DO NOT enter the deatails of Her Medical

Doctor or Clinic *

Doctor or Clinic Phone Number *

Doctor or clinic Fax Number

Doctors Provider Number

Doctor or Clinic Email Address

Doctor or Clinic Address *

Our preferred method of receiving medical files is via medical objects.

Our software we use is Best Practice, therefore we can accept an XML or PDF file sent via email.

Type of medical information requested *

Patient Health SummaryEntire Medical RecordMedical QuestionnairePathology investigationsRadiology investigationsMental health care planGP Management plan

Her Medical Treating Doctor *

Dr Donna Tanchev-431962JJDr Paula Hade- 4200928WDr Chris Briggs- 283435RKDr Elizabeth Colebourne- 229315QBDr Megan Kelly-434194JJDr Isabella Panettiere- 5406646XDr Vladana O'Neill- 465859BXDr Natasha Feingold-450742HXDr Christine Greenwood- 462917YT

Patient Authority

I authorize the release of requested medical information to my new provider at Her Medical

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