"*" indicates required fields

Please Note: Adults must authorize the release of their own medical file i.e. a person cannot authorize the release of their spouse's medical file. A consenting parent/guardian can sign on behalf of children under the age of 18.
Patient(s) Information:*
Name of Patient
Date of Birth
Are you Relocating?*
Date you require patient records (Please note that we have a processing time of 7-14 days). If you have future appointments booked, please be sure to select a date after your last visit to our clinic*

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