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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.