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Release of Information Consent

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Release of Information Consent

To support your care with Dr Kristian Sørensen, we may require access to relevant medical information from your other healthcare providers. This can include recent clinic letters, test results, or reports necessary for pre-operative or peri-operative planning.

Please complete the form below to provide your consent for the release of this information to FNQ Plastic Surgery. Once submitted, we will use this consent to request the relevant documents directly from your nominated provider.

If you have any questions or would prefer to complete this form in clinic, please contact our team.

Release of Information Consent

This field is for validation purposes and should be left unchanged.
Release of Information Consent(Required)
Your name(Required)
Please enter your name
Date of birth(Required)
Please enter your date of birth.
By signing your name, you acknowledge and agree that this electronic signature is the legal equivalent of your handwritten signature, and you confirm that you have read and consent to the release of your medical information as outlined above.
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Please upload relevant photos of what you are trying to achieve or your current situation. This may help you get an earlier consult appointment or surgery.

Please only include pictures of your face if relevant to your enquiry.