Email Request for Personal Records
Patient Details
Patient Full Name
*
Contact Number
*
DOB:
*
Address
*
Email:
*
Information Requested
Doctor
Description of information required
*
Provide as much information as possible. e.g blood test results from 1/9/23.
Have you tried to access this information on your MyHealth record?
*
Yes
No
Generally results are available on your myGov Health Record 7 days after they are released to your doctor. Most easily accessed through the "my health" app.
Have you discussed the requested information with your doctor
*
Yes
No
Results must be discussed with your doctor prior to release. Your doctor must approve the release of information.
Transferring health information by email is not secure and advised against. Do you understand the risks and consent to receiving the requested information by email?
*
Yes
No
Patient's signature:
Clear
Date:
Parent or Guardian signature
Clear
Date
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