Release Of Medical Records

Release Of Medical Records
Patient Name:

First NameLast Name
Today's Date

MonthDayYear
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

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