Medical Release Form

Patient Name:

Date of Birth:

Email:

Phone Number:

This authorizes the release of my records to/from Four Seasons Dermatology.
The records shall be sent to/received from:

The records shall include, but not be limited to the following:


To include dates

From:
To:

I would like to pickup the records on:

 

OR

Please mail the records to the following address:

 

 

 

 


Provider's Phone Number:


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Sign Here:

Date:


Please note that Medical Release requests are processed within 7-10 business days.
Information will be verified in person.