Patient Demographics

Why we ask this

We collect this information to verify your identity and to process your request to access or release your health records.

Patient's full name(Required)

Date of birth(Required)

Patient's Address(Required)

Street Address Address Line 2 City State Postcode Country

Records Requested From (Healthcare Provider Details)

Please provide the contact details of the healthcare provider or facility whose records you are authorising us to request. Complete as many fields as possible, but do not be concerned if you do not have all the information - any details you can provide will assist us in making contact.

Provider / Facility Name(Required)

e.g. St Vincent's Hospital, Dr Smith's Practice

Provider's Phone Number, if known

Provider's Email Address, if known

Provider's Website, if known

Provider's Address

Street Address Address Line 2 City State Postcode Country

Type of Records Requested

Please select only the records you are authorising for release(Required)

Other(Required)

Please specify what other record types you are authorising for release

Approximate dates / period of treatment

Leave blank if you wish to authorise release of all records held

Records will be released to:

Dr Jill Tomlinson
549 Bridge Road, Richmond VIC 3121
Phone: 03 9427 9596 | Fax: 03 8677 9116

I request and authorise the healthcare provider(s) and/or facility specified in this form to release my healthcare information to:

Dr Jill Tomlinson
549 Bridge Road, Richmond VIC 3121
Phone: 03 9427 9596 | Fax: 03 8677 9116

This authorisation applies to the records and date ranges specified above, including but not limited to operation reports, medical notes, outpatient notes, pathology results, radiology reports and images, and nerve conduction studies.

I understand I may revoke this authorisation at any time by contacting Dr Tomlinson's practice in writing.

Signature(Required)

If you are signing as a representative, your signature confirms you have legal authority to authorise the release of this patient's healthcare information.

Relationship to Patient(Required)

Self

Parent

Legal Guardian

Power of Attorney

Signer's full name(Required)

As the authorised representative signing on behalf of the patient, please provide your full name.

Relationship detail(Required)

Please specify your exact relationship or legal capacity.

Authorisation to release healthcare information

Patient Demographics

Why we ask this

Records Requested From (Healthcare Provider Details)

Type of Records Requested