I hereby authorize the release of all necessary medical records to:
Julie Tomberlin MD PA706 Hunters Row Ct.Mansfield, TX 76063Phone: 682-518-8111 / Fax: firstname.lastname@example.org
Disclaimer: 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.
Your information will be encrypted.
Your browser does not support capabilities required for electronic signatures.
Click a signature you want to use:
Copyright © 1999-2024 Hush Communications Canada Inc.