Request for Patient Record

Date:

To:

Fax Number

From:

Please note: The information contained in this fax is confidential and may be legally privileged. It is intended for receipt only by the stated addressee. Any use, disclosure, copying, distribution of this facsimile or any information contained therein is prohibited. Please advise us immediately if this communication was received in error. Thank you.

The following patient has registered with our Long COVID clinic. We kindly request that you send an up to date health summary and copies of any recent relevant investigations, including any ECGs, lung function testing, radiology and pathology prior to their first appointment with us.

The patient's first appointment with the Long COVID Clinic is on:

Date of your first Long COVID Clinic Appointment

As we use Best Practice, our preference would be for this informatin to be sent in XML format via email to records_indo@ihealthcentre.com.au. Alternatively, please send via Medical Objects or Fax to 3870 0583

The patient is aware that your clinic may generate a reasonable fee payble by them for this request.

Full Name *

Date of Birth *

Address *

PATIENT’S AUTHORISATION

Patient/Guardian Signature

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Name of Patient/Guardian