AFFZ11 Medical Records Release Form

Medical Records Release

Patient Name *

First Name

Middle Name

Last Name

Date of Birth *

Date

I hereby authorize Affiliated Dermatologists, S.C. to release my medical records to:

Doctor or Facility *

Address

Street Address

Street Address Line 2

City

State / Province

Postal / Zip Code

Fax Number *

Please enter a valid phone number.

Digital Signature Authorization: *

I certify that I am the person represented on this form or I have the legal authority to sign on their behalf. I also understand that the digital signature below is a valid legally binding signature.

Patient Signature *

Date *

Date

Date *

Date