Medical Record Release Authorization

Please make sure to complete all 3 sections & click on the submit button. If you don't click on the submit button, it does not get processed.
Today's Date

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Medical Record Release Authorization

Ikeda Optometry Inc
Patient Name*

First NameLast Name
Patient Birth Date*

MonthDayYear
Name of Doctor's Office

First NameLast Name
Fax Number
Fax Number
Medical Office Location*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Authorization of Medical Release

I authorize Ikeda Optometry to obtain my medical records on my behalf from any previous medical/ocular exams. Please release my past medical records in its entirety to Ikeda Optometry when requested.
Responsible Party's Signature (please sign with your finger directly on the surface or with a mouse)*

Clear
Signature (if under 18 years old, parent signature required)
Date/time signed

MonthDayYearHourMinutesAM/PM Option
Should be Empty:

Please make sure to complete all 3 sections & click on the submit button. If you don't click on the submit button, it does not get processed.