Greytown Medical Record Transfer Form In order to receive the best possible care, I agree to Greytown Medical Centre obtaining my medical records from my previous doctor. I understand that I will be removed from My previous practice register. (Each person 16 years or over must complete and sign their own form) Previous Medical Centre Medical centre address Phone Preferred Doctor/NurseNP Rachael PretoriusNP Nicole Kolvenbag The following person/s have enrolled with Greytown Medical Centre. Please transfer thier medical records. Family Name First Name Date of Birth NHI Number Where possible could electronic records please be sent via GP2GP Healthlink EDI: grytnmcg GP2GP : Nicole Kolvenbag No: 164359 Rachael Pretorius No: 140471 Signed* Date If signing this form on behalf of another person (usually a child under 16 years of age) please state your name and relationship to them Name Relationship
