southernentandsinus.com - Release of Medical Records TO Southern ENT & Sinus Center

RELEASE OF MEDICAL RECORDS AND/OR INFORMATION
I, Name , Authorize:
Name:
Fax Number:
TO RELEASE MY RECORDS TO:
SOUTHERN ENT & SINUS CENTER, P.C.

D. Trent Lowery, MD; David Walters, MD; Matthew Fort, MD

1809 Gadsden Highway
Birmingham, AL 35235

205-228-7970 (fax) 205-661-0127
PATIENT'S NAME:
PATIENT'S DATE OF BIRTH:

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Date
Signature of patient or responsible party

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Date

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Date
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