Medical Records Release Form Houston Heartburn and Reflux Center

Medical Records Release Form

Elias Darido, MD, FACS

Houston Heartburn & Reflux Center
Houston Weight Loss Surgery Center
Patient's Full Name*

First NameLast Name
Date of Birth*

MonthDayYear
Date
EGD Report w/pathologyManometry TestingGastric Emptying StudyUGI ReportCardiac ClearanceSurgery ReportPH BravoEntire Medical Record
**Surgery Type
List Name of Surgery Report Requested
**Date of Surgery

MonthDayYear
Date

Please list below the physicians that have the above requested reports.

I {patientsFull}, authorize the release of information including the diagnosis, records, and examination rendered to me by the physicians listed above to Dr. Elias Darido.

(Ph. 832-945-8717) (Fax# 281-762-1452)
Signature of patient

Clear
Date

MonthDayYear
Date
The Patient/Authorized Representative has read this form, or had it read to him/her.The Patient/Authorized Representative states that he/she understands this informationThe Patient/Authorized Representative has no further questions
CERTIFICATION OF PHYSICIAN: I hereby certify that I have discussed with the individual granting consent, the facts, anticipated benefits, material risks, alternative therapies and the risks associated with the alternatives of the procedure(s).
Doctor Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Medical Records Release Form