Transfer of Medical Records Enquiry

Please complete this form to request the transfer of your medical records from Double Bay Doctors to an external healthcare practitioner.

A $35 administration fee applies to all transfer requests.

Please allow up to 10 business days for your request to be completed.

PATIENT DETAILS

Date of Submission

First Name *

Last Name *

Date of Birth *

Contact Phone Number *

Residential Address *

Email Address Verification *

Send code

Do you also wish to transfer records for any of your children or dependants? (Any patients aged 16 years and over must complete their own form) *

YesNo

If you answered yes, please provide us with the full name and dob for each of your dependants below

External Medical Practitioner or Practice Name *

Medical Practice Phone Number

Medical Practice Fax Number

Medical Practice Email Address

Medical Practice Address

Signature *

Clear

Date *

Administration Fee – Transfer of Medical Records ($35) *

Pay