Health Practice Closure, Merger or Relocation Online Form - ACT Government

Is the practice: *

Closing
Merging
Relocating

Have you placed a public transfer notice of the closure, merger or relocation of the practice in the local newspaper? *

Yes
No

Name of Current Practice *

Street

City/Suburb/Town

State/Territory

Postcode *

Phone Number *

Fax Number *

Email Address

Where will health records be held? *

relocated practice
other, please specify

Name of merged or relocating practice, or name of location of health records

Street

City/Suburb/Town

State/Territory

Postcode *

Name of record keeper

Phone Number

Fax Number

Email Address

When will health records be moved? *

Day Month Year

Your name and designation in the practice?

Name of Contact Officer for Queries and Complaints

Street

City/Suburb/Town

State/Territory

Postcode *

Phone number

Fax number

Email Address

This page is managed by: ACT Health Directorate