Medical Release Form

    Patient Name:

    Date of Birth:

    Email:

    Phone Number:

    This authorizes the release of my records from Four Seasons Dermatology.
    Records should be sent to:

    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:


    Enter Captcha Code: captcha

    Sign Here:

    Date:

    If you would like Four Seasons Dermatology to have a copy of your records from your previous dermatology doctor, please contact their office for instruction.


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