Park Cities Eye Associates
8115 Preston Road, Suite 630, Dallas, Texas 75225
phone 214-360-9951, fax 214-360-9819, www.parkcitieseye.com
REQUEST FOR MEDICAL RECORDS
TO:
Name: ___________________________________
Address: ___________________________________
City/State/Zip: ___________________________________
Phone / Fax: ___________________________________
I request that you release a copy of my medical records (including spectacle and contact lens prescriptions, visual fields, photos, etc) directly to Cathy Norton, O.D. at Park Cities Eye Associates.
Printed Patient Name: _____________________________
Patient Date of Birth: _____________________________
Patient Signature: _____________________________
Date Signed: _____________________________
Please fax these records to 214-360-9819. In addition, please mail any color documents, such as fundus photos or corneal topography to Dr. Norton, 8115 Preston Rd, Ste 630, Dallas, TX 75225. Thank you in advance for your prompt attention to this request.