"*" 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 PatientDate of Birth Add RemoveAre you Relocating?* Yes No Any additional Information?* 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*Day12345678910111213141516171819202122232425262728293031Month123456789101112Year20232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Phone Number*Email Address* Signature*Acknowledgement* Please note - If you are set up for Insurance Direct Billing and relocating, we can no longer direct bill with your insurer after we have released your patient record. All future visits will be self-paid, whereby you can proceed to claim directly with your insurer. Consent* I/We hereby request and authorise International Medical Clinic to release information from the medical file of the following patient(s) below. Please note adults must authorise the release of their own medical file i.e. a person cannot authorise the release of their spouse’s medical file. A consenting parent/guardian can sign on behalf of children under the age of 18. Your medical records will be emailed to you as a password protected PDF document.