Medical Release Form

Patient's Legal Name

First

Last

Date of Birth

Phone

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:

If your provider only requires the the last visit note and pathology/lab reports, please check this box
Patients Progress Notes
Pathology Reports
Lab Reports
Other

To include dates

From

I would like to pickup the records on:

Please mail the records to the following address:

Address Line 1

Address Line 2

City

State

Zip Code

Provider's Phone Number

Signature *

Date *

Please allow 7-10 business for processing.

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.