Medical Release Form

    Patient Name:

    Date of Birth:


    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


    I would like to pickup the records on:



    Please mail the records to the following address:





    Provider's Phone Number:

    Enter Captcha Code: captcha

    Sign Here:


    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.