Request medical record | Queensland Eye Institute

Step 1 of 2

About You

QEI requires information about you to confirm you are the owner of the medical record being requested.

Your Name(Required)

Title First Last

Your date of birth(Required)

Your Address(Required)

Street Address Address Line 2 City State Post Code

Your Email Address(Required)

Email Address Confirm Email Address

Your Phone(Required)

Providing a Medicare number assists QEI in identifying the correct medical records. If you do not have a Medicare card, leave this blank.

Your Medicare number

Ref

Your number on the card

Where to send your record

Where the information is requested to be sent to someone other than you the patient (or patient guardian), please provide their full contact details below.

Please select where this record should be sent(Required)

Patient (or patient guardian)

Patient-nominated health care provider

Patient-nominated other third party

Name of other provider or third party

Prefix First Last

Practice name of other provider or third party

Where this practice operates at more than one location, please specify the practice name and location EG "Specsavers Fairfield"

Practice Address of other provider or third party

Street Address Address Line 2 City State Post code

Practice Email of other provider or third party(Required)

Enter Email Confirm Email

Consent to Terms and Conditions(Required)

I have read and accept the terms and conditions and privacy policy

Signature(Required)

Use your mouse or stylus to sign here. QEI will compare this signature to the one filed with the medical record being requested.

About You

Where to send your record

Payment

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