Medical Release Form

Medical Release Form

This form will be kept on file for one (1) year as a medical release.
Patient Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Cell Phone Number*

Area CodePhone Number
Please release my medical records from:
Name Of Provider

First NameLast Name
Provider Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel

Area CodePhone Number
Fax

Area CodePhone Number
Notes:
Send Medical Records To:

Hetel Bhakta, O.D.

Planet Vision Eyecare

8755 Hypoluxo Rd Suite 2

Lake Worth, Florida 33467

Tel: (561) 965-7600

Fax: (561) 965-2821
Please release all medical records

I HEREBY AUTHORIZE THE RELEASE OF MY MEDICAL RECORDS AS PROVIDED ABOVE
Signature*

Clear
Parent / Guardian
Submitted Date*

MonthDayYear
Date
Should be Empty: