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.