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Records Release Form

 

Park Cities Eye Associates

 

8115 Preston Road, Suite 630, Dallas, Texas 75225

phone 214-360-9951, fax: 214-360-9819, website: www.parkcitieseye.com

 

RELEASE OF MEDICAL RECORDS

I authorize Park Cities Eye Associates to release my medical records to:

Name: ___________________________________

Address: ___________________________________

City/State/Zip: ___________________________________

Phone / Fax: ___________________________________

Reason: ___________________________________

 

Printed Patient Name: _____________________________

Patient Date of Birth: _____________________________

Patient Signature: _____________________________

Date Signed: _____________________________

Please fax completed form to us at 214-360-9819.