Records Release Form

Name of Patient

Date of Birth

Add additional patient

Address

City

State

Zip

Please release the medical records from the office of Medical Center pediatrics and send them to:

Name

Address

City

State

Zip

I authorize the release of medical records obtained in this office.

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.

Signature of Patient (if 18 years or older) or Patient or Guardian:

Telephone Number

Date

If Dissastified with Office or Other, please explain:

Your information will be encrypted.

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