Records Release Request
Please use this link to request your records for Dr. Valenzuela
Patient Name
*
First Name
Last Name
Date of Birth
*
-
Month
-
Day
Year
Date
Email
example@example.com
Phone Number
Please enter a valid phone number.
I would like to request all of my medical information and records to be transferred to Nimbus Health so I can continue my care with Dr. Valenzuela.
Unless you state otherwise, this authorization includes the release and disclosure of all medical records and information, including but not limited to paper and electronic records, x-rays, films, and other documents, except as otherwise noted below. This authorization includes the release of any information regarding treatment or referral for substance abuse.
Please sign below and date it.
Signature
*
Submit
Submit
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