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Records Request Form

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.