Authorization for release of medical records

Authorization for release of medical records
To Doctor or Practice Name:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
Please send copies of my child's/children's complete medical records to the following address:

Flourish Pediatrics

8601 Dunwoody Pl, Suite 565

Sandy Springs, GA 30350

Phone: 470-500-6844

Fax: 833-992-2227
Child's Name
Date of Birth

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
Child's Name
Date of Birth

MonthDayYear
Date
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Signature

Clear
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty: