Medical History Request - Release my records to my new GP

Medical History Request - Release My Records To My New GP

Please complete the form below to request Stratford Medical Centre send your records to your new GP.

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

Patient Name:

Date of Birth:

Address

Phone:

New Doctor/Practice Name:

Address:

Phone:

Fax:

Please send the following information to my new GP:

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

Date:

Signature: