Records Request

Consent to Release Records
Full Name *

First Name Last Name
Phone Number *
Date of Birth: *

Month Day Year
Date
E-mail
Gender *

Male Female
Date of Birth:

Month Day Year
I, *
Name
hereby authorize the named parties to release any medical information including the diagnosis, medical records, and X-Ray imaging rendered during my treatment.
Parent or Guardian Relationship:

Mother Father Legal Guardian
Office or Doctor Name: *
Office we are requesting records from
Address:

Street Address

Street Address Line 2

City State

Zip Code
Office Phone Number:

Area Code Phone Number
Office Fax Number:

Area Code Phone Number
Release the following requested records:

Spinal X-Ray Imaging
Release to:

DeYoung Chiropractic

400 68th ST SW

Grand Rapids, MI 49548

P: 616-281-2500

F: 616-281-2502

E: info@DeYoungChiropractic.com
Patient or Parent/Guardian Signature *

Clear
Should be Empty:

Consent to Release Records