www.houstondermatologyassociates.com - Medical Records Request Form

MEDICAL RECORDS REQUEST
Name*

First NameLast Name
I {name} hereby authorize and request of:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
to forward a copy of summary of the following medical records:
Complete Medical RecordsBiopsy Pathology Report(s)Laboratory Report(s)Medication AllergiesSurgical ProceduresPathology Slide(s)
for dates of service from Date to Date
To
Farah Shah, M.D.Jennie A.O. Duffy, M.D.Emily Mintz, M.D.Zena Zoghbi, M.D.
Mailing Address:

6560 Fannin, Suite 1720, Houston, TX 77030
Name of Patient (Print)*

First NameLast Name
Patient’s Date of Birth*

MonthDayYear
Patients Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

MEDICAL RECORDS REQUEST