Medical History Request - Send Records to Cairns Health Collective

Please complete the form below to request your medical records from your previous doctor/practice, and have them send to Cairns Health Collective.

If you prefer to download a PDF version of the form, download the form here.

Patient Name:

Date of Birth:

Address

Phone:

Previous Doctor/Practice Name:

Address:

Phone:

Fax:

Please send the following information to my new GP at Stratford Medical Centre:

If "Other" selected above, please list the specific information you are requesting:

Date:

Signature: