Authority to Transfer Medical Records to
Newdegate Street Health Centre

--- Details of your Old Practice* ---

--- Your Details ---

Date of Birth (DD/MM/YYYY) *

Address*

Phone Number*

Email Address*

Name of Patient

Declare and Sign Below
-I declare that I have filled in the form truthfully.
-I declare that I am the legal guardian or EPOA if completing this request for a person other than myself.
-I authorise my current Medical Clinic to Transfer my medical records to Long Beach Medical Centre.
-I request that the transfer be made in a digital format where possible.