Medical Records

Records release authorization.

I hereby authorize and request you to release my medical records, including my immunization history, in your possession concerning my illness and/or treatment.

Records requested

Complete medical records including vaccinations Vaccination records only Specific treatment/date Most recent office note/labs/testing

Treatment date Name Email Date of birth Address Previous physician name Previous physician address Previous physician phone Previous physician fax Choose physician Signature Today's date I authorize the release of these records.