Medical Records Form

REQUEST FOR MEDICAL RECORDS

I authorize:

(name of doctor or clinic releasing information to Burgess Pediatrics )

To release medical records of:

Patient Name:

Date of Birth:

Including:

Medical evaluations

Vaccination history

Growth records

Radiology reports

Laboratory evaluation

Fax To: 650-321-9556

James Cisco, MD Sarah Cueva, MD Margaret Miller, MD

Name of individual requesting records:

Relationship to patient:

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

Signature:

Date:

Your information will be encrypted.