Request for Transfer of Medical Records

Date

Name of Patient

Patient's Date of Birth

I HEREBY AUTHORIZE YOU TO FURNISH ANY AND ALL INFORMATION YOU HAVE REGARDING THE ABOVE PATIENT’S MEDICAL HISTORY AND PHYSICAL CONDITION, INCLUDING IMMUNIZATIONS TO:

MICHAEL TAYMOR, MD

145 N. CALIFORNIA AVE.

PALO ALTO, CA 94301

TEL: (650) 321-7722

FAX: (650) 326-7775

THANK YOU FOR YOUR COOPERATION.

YOURS TRULY,

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.

Authorizing Signature

Relationship to Patient

Self

Mother

Father

Legal Guardian

Primary Care Physician

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