Medical records

Name of patient*
First Last
Patient's Date of Birth*
Day
Month
Year
I am*
- the patient.
- the parent/guardian of the patient
- other.
There are current court orders regarding the guardianship or welfare of the patient.*
- yes
- no
Please describe your relationship to the patient.*
Name of person completing the form*
First Last
Treating Clinician at Newcastle Health Enterprise*
- A/Prof Ryan Winters (ENT)
- Dr Niall Jefferson (ENT)
- Dr Francois Abel (respiratory/sleep)
- Prof Joerg Mattes (respiratory/sleep)
- Dr Vivek Rajasekaran (gastroenterology)
- Dr Rani Bhatia (allergy/immunology)
- Newcastle Hearing Centre (audiology)
I am*
- requesting copies of my medical record for myself.
- requesting that my medical records are transfered to another doctor/practice.
Briefly describe the reason for the request.*
Documents requested*
How do you wish to receive this information*
- hard copies in the post
- email
- collect in person
Please transfer my medical records to*
First Last
Location, email and phone of practice the records are to be sent.*
Documents requested*
I would like the practice named above to be added as an "interested party" and receive copies of future correspondence regarding my care from from Newcastle Health Enterprise*
- yes
- no
Signature
Your Name
Your Name
Your Name