Please Note: If you are over 18, all Requests for Release of Patient Medical Information must be completed and signed by the individual. You can add your dependants to your own form, however your spouse will need to complete and sign their own.Patient(s) Information:*Name of PatientDate of Birth Reason for Release of Information*Date you are leaving Singapore* Date Format: MM slash DD slash YYYY Phone Number*Email Address* Signature*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.