Peninsula Doctor Medical Release

By signing the form below, I authorize the release of my medical records to Peninsula Doctor.

Patient Name:

Date of Birth

Email address

I hereby authorize (name of your current medical practice)

To release copies of my medical records to be sent to:

Peninsula Doctor
Attn: Dr. Kroes & Dr. Hiroshima
401 Burgess Dr. Suite D, Menlo Park, CA 94025
Phone 650.800.3365
Fax 650.252.0043 (Do not fax more than 15 pages)

Medical information includes

All records

Radiology results only

Lab results only

Mental health records only

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

Signature

Date

Your information will be encrypted.