Medical Release Form
Dr. Daniel Lacroix 17589 County Rd 44(Headline Road East ),South Stormont, K0C 1P0 Fax: 613-703-0267, Phone: 613-7761611 x2, x7 Email: drlacroix@moosecreekmed.ca
Patient's full name
First Name
Last Name
Date of birth
Phone Number
Please enter a valid phone number.
Address
Street Address
Street Address Line 2
City
Province
Postal Code
Name of previous family physician
First Name
Last Name
Address of previous family physician
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Phone Number of previous family physician
Please enter a valid phone number.
Fax Number of previous family physician
Please enter a valid phone number.
It is hereby requested that for each person named below, a medical file summary be prepared and forwarded to my new physician at Dr. Lacroix's Clinic. Please include all medical reports, excluding lab reports
Name
First Name
Last Name
Date
-
Month
-
Day
Year
Date
Signature
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