Medical Records Request & Release Form

Medical Records Request & Release Form 2018-08-08T07:10:55+00:00

Ready for treatment that works? Fill out this form before your appointment so we can begin your screening without delay. If you wish to fill this form out in the office instead, please arrive 15 minutes before your appointment time.

Your privacy is important, and protected by law. Let us know who can access your records.

  • I, the undersigned, hereby authorize

  • This field is for validation purposes and should be left unchanged.

Restoring Hope

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