Sherbourne Road Medical Clinic
111 Sherbourne Rd. Montmorency 3094
P.O. Box 61, Briar Hill 3088
Telephone: 9435 1144    Fax: 9432 8687
srmc@netspace.net.au
www.sherbourneroadmc.net.au

	To: Dr…………………………………………………………………….

	At: ………………………………………………………………………..

	      ………………………………………………………………….…….

	Fax: ………………………………………………………………………

	
	Re: ………………………………………… DOB : …………………….

The patient above has attended this clinic.

In order to assist with his/her future management, we would be pleased if you would forward a summary or copy of the patient’s history and any relevant investigation results and correspondence.

If you are using Medical Director to record your medical records we would prefer the file delivered on a disk in xml format.

Patient Consent:

I hereby request and provide my written consent for release of details of my past medical history and treatment to Dr ………………….……….. 
at Sherbourne Road Medical Clinic, 111 Sherbourne Road, Montmorency, 3094.

Yours sincerely

Signature: ………………………………………   Date: …………………………………