Private Client Consent to Transfer

A few things still need answering

Your details

Fields marked with a red star are the ones we need to request your file.

Title

First name Please enter your first name

Last name Please enter your last name

Date of birth

Day

Month

Year

Please enter a valid date of birth

Street address Please enter your street address

Town or suburb Please enter your town or suburb

Postcode Please enter a 4-digit postcode

Mobile phone Please enter a contact number

Home phone

Email address Used to send you a copy of this request Please check the email address, it does not look quite right

Your previous provider

Tell us who you are transferring from, so we know where to request your file.

Clinic or company name If you are not sure of the exact name, tell us what you remember and we will find it Please tell us who your previous provider was

Where is that clinic? The town or suburb is enough

Transfer request and consent

Please read this, then sign at the bottom.

I have read and agree to the above This authorises your previous provider to release your file to AIM Hearing. Please tick to give your consent, we cannot request your file without it

Your signature

Type your full name below. Under the Electronic Transactions Act, this counts as your signature when you also tick the box confirming you intend it to.

Type your full name Please type your full name to sign

Signed on —

I confirm this is my electronic signature I am the person named above, and I intend this typed name to have the same effect as my handwritten signature. Please confirm your electronic signature

Email me a copy of this request for my records Recommended. Untick if you would rather not receive one.

Send my copy to Please enter an email address, or untick the box above

Sent securely to reception@aimhearing.com.au. Nothing is stored on this page.

Thank you, your transfer request has been sent

We will contact your previous provider and request your file. There is nothing else you need to do.