Medical Records Release Form
Specsavers Southcentre - Theo Buzea Professional Corp - Southcentre Mall 100 Anderson Rd SE Calgary, AB, T2J 3V1 - Phone: 587 441 5254 - Fax: 587 441 6668 - Email: store.southcentremall.ca@specsavers.com
Clinic Requesting Health Information From
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By signing this form, I (patient name listed below) authorize Specsavers Southcentre to request my previous health records on my behalf. The information you may release subject to this signed release form is as follows:
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Spectacle and Contact Lens Rx
Contact Lens Specifications
Summary of Previous Comprehensive Eye Exam
Summary of Any Extra Testing and Examinations (i.e. glaucoma, etc.)
Patient Name
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First Name
Last Name
Date of Birth
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Day
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Month
Year
Date
Patient Signature
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Date Signed
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Day
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Month
Year
Date
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