Records Release "TO" Tosa Pediatrics Form

Medical Records Release Form

This form is to be used to obtain records from another medical office and sent "to" Tosa Pediatrics. One form is needed per child.
Child's Name*
Child's Date of Birth*

MonthDayYear
Date
Child's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone*
Email*
example@example.com
Records Released From:
Name (i.e. health facility, physician)*
Facility Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Facility Phone #*
Facility Fax #*
Information to be released:*

Complete copy of all recordsImmunization RecordsGrowth ChartsOther
I, the guardian/parent/patient authorize the release of all medical records for the above listed patient in accordance with the specification listed above. I understand that I have a right to inspect and receive a copy of the disclosed material. A photocopy of this consent shall be valid as the original.
Signature*

Clear
Relationship to Patient*
Date

MonthDayYear
Date
Should be Empty: