Patient consent

Consent to transfer records

Complete this form to authorise the University of Sydney to provide AODI with copies of your medical records to support your ongoing care.

Patient Consent to Transfer Medical Records

University of Sydney to AODI

Please complete this form if you would like the University of Sydney to provide AODI with copies of your medical records to support your ongoing care.

AODI will provide services temporarily at Gordon Eye Surgery from mid-October 2026. The receiving healthcare provider named in this consent is AODI.

Please complete one form per patient.

1. Patient details

First name*Middle name(s)Surname*Previous name, if relevantDate of birth*Contact telephone number*Email addressPatient reference number, if knownPrevious treating clinician, if knownApproximate dates of care, if known

Residential address*

2. Who is completing this form?

I am the patient.I am authorised to provide consent on the patient’s behalf.

3. Transfer details

Organisation releasing the records:
The University of Sydney, including records held through the Save Sight Institute.

Organisation receiving the records:
Australian Ophthalmic Diagnostic Institute (AODI).

Purpose:
To support the patient’s continuing ophthalmic care with AODI.

4. Records to be transferred

Please select one:

All University-held records relating to my ophthalmic care, including consultation notes, referrals, correspondence, electrophysiology reports and recordings, imaging, investigation results, treatment plans and monitoring records.Only the following records:

Information you do not wish to include, if any

5. Consent

I authorise the University of Sydney to release copies of the records selected above to the Australian Ophthalmic Diagnostic Institute (AODI) for my continuing care.

I authorise AODI to submit this consent to the University, request and receive those records on my behalf, and use them to support my assessment, treatment and ongoing monitoring.

I understand that:

The records may contain sensitive personal and health information.
This consent applies to the records specified above and their transfer to AODI.
AODI and the University may contact me to verify my identity, clarify the request or confirm the authority of a person signing on my behalf.
I may withdraw this consent before the records are released by notifying AODI or the University. Withdrawal cannot reverse a transfer that has already occurred.
Copies will be transferred. The University may retain the original records in accordance with its legal obligations.
This form does not book an appointment or guarantee when the records will be received.

I have read and understood this form and consent to the transfer described above.*If signing on the patient’s behalf, I confirm that I am authorised to provide this consent.

Full name of person signing*Date*

How your information will be used

AODI will use the information in this form to verify your identity and authority, coordinate your records request and support your ongoing care. Your completed consent will be shared with the University of Sydney to facilitate the transfer.

AODI will retain the consent and records received as part of its clinical and administrative records, subject to applicable privacy and recordkeeping obligations. Please contact AODI if you have questions about this request or wish to access or correct information you have provided.