Request medical record | Queensland Eye Institute

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)

Day
Month
Year
Your Address(Required)
Street Address Address Line 2 City State Post Code
Your Email Address(Required)
Email Address Confirm Email Address
Your Phone(Required)
Your Medicare number
Providing a Medicare number assists QEI in identifying the correct medical records. If you do not have a Medicare card, leave this blank.
Ref
Your number on the card
Consent to information release(Required)
I, the patient identified above (or their guardian), consent to the release of all clinical information from my Queensland Eye Institute medical record. I consent to my record being sent digitally to my nominated email address.
Consent to Terms and Conditions(Required)
- I have read and accept the terms and conditions and privacy policy
Signature(Required)
Your Name
Your Name
Your Name
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