youkerchiro.com - Authorization for Release of Records

Dr. Steven S. Youker

3825 East State Road 64, Suite 200
Bradenton, FL 34208
Phone: (941) 750-6200
AUTHORIZATION FOR RELEASE OF RECORDS
Date:

MonthDayYear
Date
RE:
To:
(Doctor / Hospital / Imaging Center)
Address:
Phone:
Please enter a valid phone number.
Fax:
I, Name , hereby authorize the release of my records and/or X-Rays, or copies of such, and request that they be transferred to:

Dr. Steven S. Youker, D.C., P.A.

YOUKER CHIROPRACTIC

3825 East State Road 64, Suite 200

Bradenton, Florida 34208

(941) 750-6200

Fax (941) 750-9200

www.youkerchiro.com
Date of Records:

MonthDayYear
Date
Patient’s Name:
Patient’s Date of Birth:

MonthDayYear
Date
Patient’s Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

AUTHORIZATION FOR RELEASE OF RECORDS