Mansfield - Medical Release Form - Kidsville Pediatrics Mansfield 1759 Broad Park Circle South, Suite 201 Mansfield, TX 76063

Medical Release Form

Patient Name:

Date of Birth:

Address:

City:

Zip Code:

Please choose release request:

Full Record Immunization Record Only

INFORMATION REQUESTED FROM (CLINIC NAME)

Name:

Address:

City:

State:

Phone:

Fax:

SEND INFORMATION TO

Name: Kidsville Pediatrics (Mansfield)

Address: 1759 Broad Park Circle South, Suite 201 Mansfield, TX 76063

Phone: (682) 341-3910 FAX: (682) 400-1288 Email: office@kidsvillepeds.net

I, (Please input Name below), hereby grant permission for you to release confidential health information about me, or my child, by releasing a copy of my medical record, or a summary of my protected health information, to Kidsville Pediatrics.

Printed Name

Date

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

Signature

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