Forms | IMC Medical Clinic

Forms

Child's Full Name
First Last
Email*
Phone*
Date of Birth*
DD slash MM slash YYYY
Sex*
Parent/Guardian Full Name
First Last
For children under the age of 16 years, a parent/guardian must be present with the child during consultation.
Have you travelled in the past 3 weeks? If yes, where?
Clinic*
Preferred Doctor*
Preferred Doctor*
Preferred Doctor*
Preferred Doctor*
Preferred Date*
DD slash MM slash YYYY
Preferred Time*
Is this your first visit?*
Would you like to discuss any of the below? (additional costs may be incurred)*
- Sexuality
- Substance Abuse
- Mental Health and Behaviour
- None
Any Specific Concern to be discussed?
CAPTCHA
Comments
This field is for validation purposes and should be left unchanged.

"*" 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?*

Yes

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*

Phone 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 formally request and grant authorization to the International Medical Clinic for the release of information contained within the medical files pertaining to the patient(s) listed below. Please be aware that for adults, authorization is specifically required from the individual to release their own medical records; for instance, one cannot grant permission to access a spouse's medical file. In the case of minors under the age of 18, a consenting parent or guardian may sign on their behalf. To ensure the utmost security and confidentiality, your medical records will be encrypted and subsequently sent to your designated email address. Furthermore, an OTP (One-Time Password) will be sent to you via email, serving as an additional layer of security for accessing your records.