Medical Consent Form

Date*

Dear*

Address

Phone*

Fax*

Patient Details

Name*

Date of birth*

Address

Is seeing Dr Vivien Wong and requests copies of their medical documentation to be faxed to Dr Wong including:

Health summariesLetters/correspondenceOperation notesMedical imagingDischarge summariesPathologyClinical notes

This is a signed authority for you to release the health information as specified above to Dr Vivien Wong – please fax to 1300 848 988.

Name

Please prove you are human by selecting the star.