Arbor Medical Records Release

REQUEST FOR RELEASE OF MEDICAL RECORDS
How many patients are you requesting release of medical records for?*
Patient's Name*
Date of Birth*

MonthDayYear
Patient's Name
Date of Birth

MonthDayYear
Patient's Name
Date of Birth

MonthDayYear
Patient's Name
Date of Birth

MonthDayYear
Please release:*

Medical Summary, Immunization Records, Growth Charts and Last Check-upOther
Please release medical information FROM:*
Name and location of office records are coming from
Please release medical information TO:
Arbor Pediatrics
1130 N Kimball Ave, Ste 100
Southlake, TX 76092
t 817-865-3564 
f 833-973-4036
I hereby authorize the above mentioned provider to release and/or disclose the medical information as requested above to Arbor Pediatrics as I have indicated. I also understand this information may contain information relating to HIV/AIDS or infection with any other communicable diseases, behavioral or mental health services and alcohol and/or drug abuse.
I consent to the release of any HIV/AIDS testing with the rest of my medical records.*

YesNo
Reasons for records release:*

Continuing medical careOther
In understand that I may revoke this authorization in writing at any time. Otherwise, the authorization shall remain valid until such time as it is revoked in writing.
Parent/Guardian Name*
Relationship to patient*
Signature*

Clear
Today's Date

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REQUEST FOR RELEASE OF MEDICAL RECORDS