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
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