Cloud9 - Request for Release - Formstack

Cloud9 - Request for Release Header Image

Request for Release of Records

Patient's First Name:*

Patient's Last Name:*

Patient's Date of Birth*

Parent/Guardian Name:

Requesting Party Name:*

Relationship to patient:*

Phone:

Patient's SSN:

Patient's Phone Number:*

Patient's Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Patient/Guardian Email:*

Provider Name:*

Provider Phone:*

I hereby request and give permission to the above provider to provide:

Doctor's Name:*

Doctor's Fax:

Doctor's Address:*

Address Line 1

Address Line 2

City

State

ZIP Code

Any and all information which he/she may request with respect to the provider care of above patient.

Such records may include medical care and treatment, illness or injury, dental history, medical history, consultation, prescriptions, x-rays, models and copies of all dental records and medical records.

I agree to pay the cost of duplicating any records. A photocopy of this release will be as effective and valid as the original.

Patient/Parent's Signature*

Use your mouse or finger to draw your signature above

clientID