Request for Medical Records

Phone: (07) 5623 3308 Fax: (07) 5623 3309 Email: admin@goldcoastbreastcentre.com.au

Address:1/63 Ferry Road Southport, Queensland 4215

A copy or summary will be forwarded to Gold Coast Breast Centre for continuity of your care.

Your medical history will remain at your previous clinic for 7 years from the last consultation or until a child turns 25.

First Name *

Last Name *

Date of Birth *

Email Address *

Patient Address *

Patient Signature *

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Date *

Requesting information from:

Please enter the details of your previous clinic you are requesting the information from.

Do not enter the details of Gold Coast Breast Centre

Doctor or Clinic Name (that we are requesting information from) *

Clinic Address (that we are requesting information from) *

Clinic Contact Number (that we are requesting information from) *

Our preferred method of receiving medical files is via medical objects, provider #446994HB

Alternatively you may send via: admin@goldcoastbreastcentre.com.au or Fax: 07 5623 3309

Other Information