TRANSFERRING CARE TO FAMILY EYE WELLNESS

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION
REQUEST FOR RELEASE OF MEDICAL RECORDS TO FAMILY EYE WELLNESS

I hereby request and authorize
Doctor / Practice Name*
Fax Number*
to release the ALL records of treatment I have received to:

Family Eye Wellness

Pooja J. Patel, OD, FAAO

135 Rosewood Centre Drive

Holly Springs, NC

Phone: 984-297-8400

Fax: 984-263-2914
Signature of Patient/Parent/Authorized Representative*

Clear
Date*

MonthDayYear
Date
Printed name of Patient/Parent/Authorized Representative*
Relationship to patient
Date of Birth*

MonthDayYear
Date of Birth
Email
support@familyeyewellness.com
Should be Empty:

AUTHORIZATION FOR RELEASE OF MEDICAL RECORD INFORMATION