Southlake - Medical Release Form - Kidsville Pediatrics 2813 W. Southlake Blvd Suite 100, Southlake, TX 76092

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 (Southlake)

Address: 2813 W. Southlake Blvd Suite 100, Southlake, TX 76092

Phone: (682) 345-8010 FAX: (682) 345-5051 Email: southlake@kidsvillepds.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.

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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.

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