Medical Release Form

AUTHORIZATION TO RELEASE MEDICAL RECORDS
Client Information
Patient's Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Address
(Street Address, City, State, Zip Code)
Phone Number
Please enter a valid phone number.
Email
example@example.com
Guardians Information
Mother/Guardian's Name*
Father/Guardian's Name
Mother/Guardian's Address
(Street Address, City, State, Zip Code)
Father/Guardian's Address
(Street Address, City, State, Zip Code)
Phone Number*
Phone Number
Email*
example@example.com
Email
example@example.com
I hereby authorize Little Champs Therapy & Yoga to release any pertinent health information about my child to the following person/organization.
Name of Person/Organization to Receive Information*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Please enter a valid phone number.
Fax Number
Please enter a valid fax number.
By my signature below, I acknowledge that any prior agreement I have made to restrict or limit the disclosure of information about my child’s health does not apply to this authorization. I have read this authorization, and I agree to its terms as indicated by my signature below. I am entitled to a copy of this authorization. *

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AUTHORIZATION TO RELEASE MEDICAL RECORDS