AUTHORIZATION OF RELEASE

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I hereby request and authorize the release of all information, without limitations regarding any physical and mental condition, as revealed by your observation or treatment, past, present or future.

This includes medical, surgical and dental history, x-ray findings, diagnosis, prognosis and access to all hospital records and photocopies of the same.

I request that you release the above information to:

Doctor's Name

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Requesting Information:

Patient's Full Name

Patient's I.D. Number

Patient's Birthday

Patient's Signature

Please sign your name either using your fingers for touch devices or using your mouse.

Name

Date

Witness Name

Date

By filling out and submitting this form, you are agreeing to our privacy policy.

Agree*

Agree

I am granting permission for your company to contact me by phone, email, and SMS for service, sales and/or marketing purposes.