Record Release
Please fill out this form in its entirety to authorize the release of medical records as specified.
Patient Name
*
First Name
Last Name
Patient DOB
*
-
Month
-
Day
Year
Date Picker Icon
Requesting From:
Choose One
*
Wallingford Eye Care Center
Doctor or Practice (specified below)
Doctor or Practice Name
*
Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax Number
-
Area Code
Phone Number
Releasing to:
Choose One
*
Patient
Doctor or Practice
Name
*
Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number
*
-
Area Code
Phone Number
Fax Number
*
-
Area Code
Phone Number
Please Release
*
Most recent visit note
All records / Last 3 years
Electronic Signature of Patient, Parent, Guardian, or Personal Representative
*
Clear
Today's Date
*
-
Month
-
Day
Year
Date Picker Icon
Submit Form
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