premierfamilyeyes.com - Transfer of Medical Records

Transfer of Medical Records to Premier Family Eyecare
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

Records to be sent to:

Premier Family Eye Care
6748 Kalamazoo Ave SE
Grand Rapids, MI 49508
Phone: 616-275-2020
Fax: 616-512-6102

Premier Family Eye Care
2350 32nd Street SE
Grand Rapids, Ml 49508
Phone: 616-243-0007
Fax: 616-243-0540

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:

Transfer of Medical Records to Premier Family Eyecare

Patient Information

Records Request Form: