premierfamilyeyes.com - Authorization of Medical Records

Authorization For Release of Medical Records
Patient Information
Name:

First NameLast Name
Date of Birth:

MonthDayYear
Date
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Records Request Form:
Doctor Name:
Doctor's Office Phone:
Please enter a valid phone number.
Office Fax:
Appointment Date:

MonthDayYear
Date
I give authorization to the above doctor to release all applicable medical records to Premier Family Eye Care, including glasses and/or contact lens prescriptions, eye exam findings and test results.
Patient Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

Authorization For Release of Medical Records