Release of Medical Information

Tomball Health Care For Pediatrics

The following people have permission to obtain medical information from Tomball Healthcare for Pediatrics for patients

Name:

Relationship:

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 of Parent/Guardian or patient if 18 or Older

Date:

Your information will be encrypted.