MEDICAL RECORDS REQUEST FORM
NAME
Date of Birth
-
Month
-
Day
Year
Date
Address
ADDRESS
Street Address Line 2
CITY
State / Province
Postal / Zip Code
Postal Code
PHONE
OHIP Number
E MAIL
example@example.com
I hereby authorize and instruct you to release to the Canadian Muscle & Joint Pain Clinic the following health records
Clinic/Treatment Notes
Lab Reports
Letters
Test Results
X-Rays & Reports
MRI/CT REPORTS
All Records
Other (please state)
For all the above this shall be your full and sufficient authority.
Dated this
/
Month
/
Day
Year
Date
Signature
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