Records Release Authorization

Pediatrician/Office:

Name:

Address:

Phone Number:

Fax Number:

Email:

I hereby authorize and request that you release The Immunization Records and Summary of Treatment During the period from (Start Date) to (End Date)
To: Pediatrics on Hudson 615 Broadway Hastings on Hudson, NY 10706
Phone: (914) 963 – 1663
Email: forms@pediatricsonhudson.com (preferred)
Fax: (914) 415 – 4918

For the following patient(s):

Start Date:

End Date:

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Home Address:

City:

State:

Zip:

Phone Number:

Email:

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application

Parent/Guardian Name:

Parent/Guardian Signature:

Date:

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