Dear Doctor
RE:
Request to transfer Medical Records
We would be grateful if you could transfer the records of the below named patient(s) to us at your
convenience. Please find written patient consent below.
Yours sincerely
__________________________
Dr N Black/Dr N Byrnes/Dr G Lavery
Patient Consent:
Name(s):
Address:
______________________________
DOB:
__ / __ / __
______________________________
DOB:
__ / __ / __
______________________________
DOB:
__ / __ / __
________________________________
DOB:
__ / __ / __
_____________________________________________________________________
_____________________________________________________________________
_____________________________________________________________________
I hereby request that my/our medical records be transferred to the Oakwood Medical Clinic.
Signature:
______________________________
Date:
______________________________
Oakwood Medical Clinic│ 9 Castlecourt Shopping Centre │ Castleknock D15
Tel: 823 5367 │ Fax: 823 1003 │ www.oakwoodmedical.ie