SUTHERLAND DOCTORS IS MOVING

Dr Loxley, Sue, Kylie and Judy are moving to Shire Family Medical, just 500m up the road to join the team at Shire Family Medical, 2/154 Flora St, Sutherland. We are delighted to keep caring for you in our new home.

So that Dr Loxley can continue to look after you, we need your permission for Sutherland Doctors to transfer your electronic medical records to Shire Family Medical. Your records will only be transferred if you sign this form.

First Name *

Last Name *

Email Address *

Date of birth *

Are you also signing on behalf of a family member or dependent? *

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Family member's full name

Family member's date of birth

Your relationship

Add 2nd family member?

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2nd family member's name

2nd family member's date of birth

2nd Your relationship

Add 3rd family member?

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3rd family member's name

3rd family member date of birth

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Add 4th family member?

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4th Family member's name

4th family member's date of birth

Your relation to 4th family member

Add a 5th family member?

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5th family member's name

5th family member's date of birth

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I consent to Sutherland Doctors transferring mine and my relatives' electronic medical records to Shire Family Medical so that Dr Loxley can continue to provide my care.

*

Signature *

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