Health Summary Request Form

Health Summary Request Form

This form allows Triniti Health to request a health summary from your usual GP or healthcare provider, including relevant medical history, current and past medications, allergies and other information required to support a safe and informed clinical assessment.

Patient Details

Please enter details of the patient below

Gender

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Patient First Name *

Patient Surname *

Date of birth

Mobile number *

Address *

Regular GP Details

Please enter details of your regular GP

Name of your regular GP clinic *

Name of the GP you regularly see there *

Phone number of your GP clinic

Email of your GP clinic *

Consent

By ticking below I consent to the GP clinic named above sharing a detailed health summary with Triniti Health containing:

- Current and past medical conditions

- Current and previous medications

- Allergies and adverse reactions

- Surgical and hospital history

- Mental health history

- Relevant family and social history

- Recent pathology or imaging results

- Current treatment plans and specialist involvement

- Other information relevant to my ongoing care

The health summary may be sent via email to hello@trinitihealth.com.au

I give consent *

Signature *

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Date *