Record Release Form

AUTHORIZATION FOR RELEASE OF RECORDS

Patient Name*
Date of Birth
Address(Street, City, State, Zip Code)
THE FOLLOWING INDIVIDUAL OR ORGANIZATION IS AUTHORIZED TO MAKE THE DISCLOSURE:
Obtaining Records From:
PURPOSE OF REQUEST
THE FOLLOWING INFORMATION IS TO BE DISCLOSED:
Last 2-3 Examinations and Any Pertinent Testing (Visual Fields, OCT, GDX)

SIGNATURE OF PATIENT OR LEGAL REPRESENTATIVE

DATE

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