Release of Records

Release of Records
East Vancouver Eye Clinic

Dr. Gary Cole & Dr. Tracy Dodd

6680 NE 159th Ave STE 102, Vancouver, WA 98682

P: 360-449-3937

F: 360-449-3094
Today's Date*

MonthDayYear
Date
Name*

PrefixFirst NameMiddle NameLast NameSuffix
Date of Birth

MonthDayYear
Date
Please list the names and birth-dates for any other children/dependents with records to transfer:
*If requesting for multiple adults, please fill out 1 form per individual*
I would like to...*

transfer records from prior office TO East Vancouver Eyetransfer FROM East Vancouver Eye to a new officeOther
Please provide us with the NAME of the office we are contacting:*
Please provide the contact information for the office we will be reaching out to: *
Doctor Name: Address 1: Address 2: City/State/Zip: Office Phone: Office Fax: Office Email:
If you are leaving our practice, please tell us why.
Consent to retrieve or forward your information: *

Clear
Please Sign
Should be Empty: