For the specified patient above, I hereby request and authorize the release of all medical records including operative reports, consultation reports, office notes, imaging studies, photographs, discharge summaries or any other necessary clinical information to and or from the following physician.
Dallas W. Homas, MD, PLLC
7902 Jones Maltsberger Rd.
San Antonio TX 78216
Phone: 210-640-6310
Fax: 210-824-2183
(Please Sign Below)