Medical Release Form Template

The Medical Release Form Template – Australia is offered in multiple formats, including PDF, Word, and Google Docs. These files are both modifiable and print-friendly, ensuring that you can easily customize them to suit your requirements.

Template – (Open)

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Sample

Medical Release Form Template – Australia

Editable | Printable

(PDF – 1) (PDF – 2)

Complete Template Online

1. Patient Information

2. Releasing Party Information

3. Recipient of Information

4. Purpose of Release

5. Information to be Released

6. Expiration of Authorization

7. Right to Revoke

8. Acknowledgment of Understanding

9. Signatures

I declare that I have read and understood this Medical Release Form and all information provided is accurate.

Date:

Patient’s Signature:

Releasing Party’s Signature:

PDF

WORD

Examples

Medical Release Form Template – Australia (1)

Patient Information:
[Patient’s Full Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email Address]

Release From:
[Healthcare Provider’s Name]
[Healthcare Provider’s Address]
[Healthcare Provider’s Phone Number]
[Healthcare Provider’s Email]

Recipient of Information:
[Recipient’s Name/Organization]
[Recipient’s Address]
[Recipient’s Phone Number]

Purpose of Release:
The purpose of this medical release form is to facilitate the sharing of medical information for the following reasons:
[Specify purpose, e.g., referral, insurance, legal matters, etc.].

Information to be Released:
Please provide the following medical information:
[Specify details, e.g., medical records, treatment history, immunization records, etc.].

Consent:
I, [Patient’s Name], hereby authorize [Healthcare Provider’s Name] to release my medical information as outlined above. I understand that this consent can be revoked at any time with written notice.

Signature:
[Patient’s Signature]
[Date]
[Witness Name and Signature (if required)]

Medical Release Form Template – Australia (2)

Patient Information:
[Patient’s Full Name]
[Patient’s Date of Birth]
[Patient’s Address]
[Patient’s Phone Number]
[Patient’s Email Address]

Releasing Facility:
[Name of the Medical Facility]
[Facility Address]
[Facility Phone Number]

Recipient of Information:
[Name of the Individual or Organization Receiving Information]
[Recipient’s Address]
[Recipient’s Phone Number]

Purpose of Release:
The medical information is being released for the following reasons:
[Specify reasons such as treatment, continuity of care, insurance purposes, etc.].

Details of Information to be Released:
I authorize the release of the following medical information:
[Specify which records, e.g., lab results, history & physical, medication list, etc.].

Expiration of Consent:
This consent is valid until [Expiration Date], unless revoked earlier in writing.

Patient Signature:
_____________________
[Patient’s Name]
Date: _______________

Printable

PDF – 1 PDF – 2

Medical Release Form Template - Australia