Authorization & Release Form

Patient Information
Full Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Sex
Phone Number (Home)

Area CodePhone Number
Phone Number (Cell)

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
You can choose to share your health information with:
Doctor/Hospital/ETC: City of Stamford

Address: 888 Washington Blvd
City: Stamford
State: CT
Zip: 06901
Phone: 203-977-0454
YesNo
Laboratory Testing Relating to COVID-19Office Notes/Procedures Relating to COVID-19Other
Patient Signature

Clear
Date of Signature

MonthDayYear
Date
Should be Empty:

Patient Information