Feedback formPlease provide your feedback below Name(Required) First name Last name Email address(Required) Enter Email Confirm Email Phone number(Required)State / Territory(Required)Please selectACTNSWNTQLDSATASVICWAOtherType of enquiry(Required)Please selectGeneral enquiryCancel an appointmentReschedule an appointmentRequest for informationMake a donationDiscuss medical optionsFeedback / complaintOtherOther location Request for information To request access to health records, please complete the Release of Information and Authorisation Form and email it to istp@mariestopes.org.au Please be aware that there is a processing fee. This fee is outlined in the form. The information will be sent to you via email, once payment has been received. There are some instances where the application fee will be waived, such as if you have a Healthcare card or a concession card. You will receive communications acknowledging your request and what the cost of processing will be. Once we have received your valid request, we will send your records within 28 days. If we require further information we will contact you to obtain more information. This could add to the waiting period. Date of Birth(Required) DD slash MM slash YYYY Address(Required) Street Address Address Line 2 City State/Territory Post code Comments or questions Subscribe to mailing list Check this box to join our mailing list. Read our privacy policy for more info about how we handle your personal details. CAPTCH Read our privacy policy for more information about how we handle your personal details.Feedback form (Old - Delete)[caldera_form id="CF576c79b63bf38"]
