Name and Address of Previous Doctor(s):

Dear Doctor

I, , would like to hereby inform you that I have chosen to attend Dr. at for the purposes of further medical care. In order to facilitate my ongoing medical care, would you please forward a copy of my medical records to this clinic at the address below:

In accordance with current legal and regulatory requirements please do not send the original paper chart. This clinic will be pleased to accept medical records in electronic format, written to CD, or records sent by PGP encrypted email (contact the clinic for PGP key and email address). I understand that this service is not covered by the provincial services plan, and that there is a charge for this service that I am responsible for. Please forward the bill for the service of reviewing, collating and copying my medical records. Thank you.

Specific medical information requested:

Whole chart or summary thereof please.

Patient Name and Current Address

Names of Dependants/Family Members also Transferring

Signature of Patient Requesting the Transfer: _______________________________________